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HOW  TO  FEEL  THE  PULSE 

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HOW  TO  FEEL  THE  PULSE 

AND  WHAT  TO  FEEL  IN  IT  / 

PRACTICAL  II IN  IS  FOR  BEGIXXERS 


BY 

WILLIAM    EWART,    M.D.  Cantab.,    F.R.C.P. 

PHYSICIAN   TO   ST.   GEORGE'S    HOSPITAL;   CLINICAL   LECTURER   AND 

TEACHER    OF   PRACTICAL   MEDICINE    IN    THE   MEDICAL   SCHOOL  ;    PHYSICIAN  TO  THE 

BELGRAVE    HOSPITAL   FOR   CHILDREN;   ADDITIONAL   EXAMINER   IN    1S91    FOR 

THE   3RD    M.B.    OF    THE   UNIVERSITY   OF   CAMBRIDGE;    LATE   ASSISTANT 

PHYSICIAN   AND    PATHOLOGIST    TO    THE   BROMPTON    HOSPITAL   FOR 

CONSUMPTION    AND    DISEASES    OF   THE   CHEST 


WITH   TWELVE  ILLUSTRATIONS 


NEW    YORK 

WILLIAM    WOOD    &    COMPANY 

1892 

\AU  rights  reserved] 


74 

/8U 


2> 
I 


^ 


TO 

WILLI  A  M     W  A  D  H  A  M 

M.D.,   F.B.C.F. 

CONSULTING    PHYSICIAN    TO    ST.    GEORGE'S    HOSPITAL 

AND   FOB   MANY   TEARS 

DEAN    OF    THE    MEDICAL    SCHOOL 

AND 

THE    STUDENTS*    FRIEND 

THIS  LITTLE  BOOK  FOR  STUDENTS  IS 

GRATEFULLY  INSCRIBED   BV  HIS  CLINICAL   PUPIL 

THE      AUTHOR 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/howtofeelpulsewhOOewar 


PREFACE. 


The  old-fashioned  arfc  of  feeling  the  pulse  holds  its 
own  in  medical  practice,  although  very  scant  notics 
has  been  taken  of  it  in  modern  medical  literature. 
On  the  subject  of  the  Sphygmograph,  the  student  has 
at  his  disposal  many  and  excellent  books,  and  this 
volume  would  have  had  no  purpose  had  it  attempted 
to  follow  the  same  lines.  It  is  specially  devoted  to 
matters  which  are  scarcely  touched  upon  in  most 
books  on  the  Pulse ;  but  which  are  deemed  of 
practical  importance.  It  has  been  my  aim  to  treat 
these  in  an  elementary  fashion,  reserving  for  later 
publication  merely  theoretical  or  personal  opinions. 
In  spite  of  their  imperfections  these  pages  may 
perhaps  be  of  service  in  directing  the  young  student's 
attention  to  the  oldest  and  not  the  least  important 
of  our  methods  of  clinical  study. 

I  am  much  indebted  to  the  editor  of  Gray's  Anatomy, 
Mr.  T.  Pickering  Pick,  and  to  the  publishers,  Messrs. 
Longmans    and    Green,    for    their  leave  to    use    two 


viii  PREFACE. 

plates  from  that  work,  and  to  Dr.  Douglas  Towell  for 
his  kind  permission  to  reproduce  his  valuable  diagrams 
of  the  pulse ;  also  to  my  nephew,  Mr.  P.  de  Vaumas, 
and  to  Dr.  H.  B.  Grimsdale  for  their  assistance  in  the 
production  of  the  other  illustrations  ;  and  lastly,  to  my 
friend  Mr.  Godfrey  Thrupp  for  his  valuable  help  in 
revising  the  proofs. 

WILLIAM   EWART. 

S3  Curzon  Street,  Mayfair, 
March   1S92. 


TABLE   OF   CONTENTS. 


Preface vii 

Introductory  Remarks 1 

CHAPTER   I. 

THE  PULSE  AND  THE  PRACTICAL  METHODS  FOR 
ITS  STUDY. 

The  Pulse  ;  Circumstances  and  Situations  favourable 

for  its  Detection .3 

The  visible  pulse  and  the  tangible  pulse — Circumstances 
favouring  or  hindering  the  detection  of  arterial  pulsation — 
Situations  in  which  pulsation  may  be  seen  in  lean  subjects 
— The  influence  of  position — Situations  in  which  the  arterial 
pulse  may  be  felt  in  most  subjects — The  common  pulses. 
The  Mode  of  Feeling  the  Various  Pulses  ....  8 
The  Seats  of  Election  for  a  Study  of  the  Pulse.    The  Radial 

Artery;  its  Advantages 9 


Description  of  the  Practical  Methods  for  the  Study 

of  the  Pulse 10 

The  Method  for  Counting  the  Pulse       .        .        .        .10 
Various  sites  for  counting  the  pulse— Counting  the  pulse 
at  the  Carotid  and  at  the  Heart — Duration  of  the  observa- 
tion— Preliminary  precautions — Rules   to   be   followed  in 
counting  the  pulse. 


x  TABLE  OF  CONTEXTS. 

TAGK 

The  Method  of  Feeling  the  Pulse 14 

I.  General  Rules  relating  to  the  Attitude  of  Body  and  Limb 

Attitude  of  the  body — The  observer's  attitude — The 
patient's  attitude — Attitude  of  the  arm — Steadiness  essen- 
tial ;  how  secured — Patient's  arm  supported  by  the  observer 
— Muscular  relaxation  essential,  in  the  observer,  in  the 
patient — Management  of  the  patient's  wrist — The  attitude 
of  the  hand — "Which  pulse  to  hold  ? — Which  hand  to  use  ? 
— The  attitude  of  the  observer's  hand — The  superior  and 
the  inferior  position  of  hand — The  arrangement  of  the 
fingers  and  their  relation  to  the  wrist — The  distal  position 
and  the  proximal  position  of  the  index  finger — The  exact 
spot  where  the  finger  should  be  placed — The  inclination  of 
the  fingers. 

II.  Exploration  of  the  Pulse .25 

The  degrees  of  pressure  to  be  applied — How  to  regulate 
the  pressure — The  behaviour  of  the  pulse  under  varying 
pressure — The  manipulation  or  fingering  of  the  pulse. 

IIT.  Methods   for   rapidly  finding  the   Pulsation    of    some 

other  Arteries 20 

How  to  find  the  beat  of  the  Facial  Artery  ;  of  the 
Temporal ;  of  the  Carotid  ;  of  the  Brachial. 


CHAPTEE    II. 

ELEMENTARY  NOTIONS  ON  THE   PHYSIOLOGY  OF 
THE  PULSE. 

The  Structure  of  Arteries.   • 34 

The  Cardiac  Systole  and  the  Pulse-Wave     .     ^  .        .35 
Velocity  of  the  pulse  wave — Velocity  of  the  blood  stream 
— Length  of  the  pulse-wave— The  pulse-wave  and  the  sphyg- 
mogram. 


TABLE  OF  CONTENTS.  xl 

I'ii.i: 

Intra-arteiual  Blood  Pressure,  and  Peripheral  Resist- 
ance   38 

The  mean  arterial  pressure  ;  the  pulse  curves  and  the  re- 
spiratory undulations — Amount  of  the  intra-arterial  and 
intra- ventricular  pressures — Amount  of  the  intra-capillary, 
and  of  the  intra-venous  blood  pressure. 

Arterial  Tension 40 

The  artery  as  an  elastic  and  contractile  tube— Influence 
of  varying  calibre  on  arterial  tension — Softness  and  hard- 
ness of  pulse— Influence  of  elasticity  on  arterial  tension. 

Dicrotism 42 

The  arterial  foot  jerk  as  a  type  of  the  sphygmograph. 


CHAPTER    III. 

THE  CHIEF  QUALITIES  AND  VARIETIES  OF  THE 
NORMAL  PULSE. 

Systematic  Description  of  the  Qualities  of  the  Pulse  46 
Large  and  small  size,  or  volume  of  pulse — So-called 
fulness  and  emptiness  of  pulse — Strength  and  weakness  of 
pulse — The  artery  during  the  interval  between  beats — Soft- 
ness and  hardness  of  pulse — Swiftness  and  slowness  of 
pulse  ;  or  short  or  long  duration  of  the  pulse-wave. 

Frequency  and  Inprequency  of  Pulse  ;  or  Pulse-Rate    51 

Accelerating  and  retarding  influences. 

I.  The  normal  rate  in  the  two  sexes. 

II.  Influence  of  age. 

III.  ,,  stature. 

IV.  „  the  hour  of  day 

V.  „  sleep,  and  of  the  waking  state. 

VI.  ,,  meals,  and  of  fasting. 


xii  TABLE  OF  CONTEXTS. 

VI L  Influence  of  the  quantity,  and  of  the  quality  of  food — 
alcohol,  tea  and  coffee. 

VIII.  „            tobacco-smoking. 

IX.  „           muscular  exercise,  and  of  rest. 

X.  .,            posture. 

XI.  ,,            emotion. 

XII.  ..            variations  in  barometric  pressure. 

XIII.  .,  ,,             the  external  temperature. 

XIV.  ..  ,,                ,,   temperature  of  the  body. 


CHAPTER    IV. 

THE  CHIEF  ABNORMALITIES  OF  THE  PULSE. 

PAGE 

The  Variations  eh  Size 59 

Unevenness  of  pulse — Periodic  unevenness — Abortive 
beats — Xon-periodic  unevenness — Linked  beats — Differ- 
ence between  linked  beats  and  pulsus  trigeminus  and  trige- 
minus— Combined  unevenness  and  irregularity. 

The  Vabxatiohs  in  Rhythm 62 

Irregularity  of  pulse — Intermittence — Allorhythmia  and 
Arhythmia — Intermittence  at  the  wrist — The  varieties  of 
Rhythm  in  intermittence — Absolute  Arhythmia — Classical 
varieties  of  uneven  and  irregular  pulse  known  under  special 
names — Pulsus  paradoxus. 

The  Incompeessible  Pulse,  So-called       .        .        .        .67 
Arterial  sclerosis — Calcification  of  the  arterial  wall. 

The  Recueeext  Pulse 60 

Circulation  by  Anastomosis — Refluent  radial  pulse. 


TABLE  OF  CONTENTS.  xiii 


CHAPTER   V. 

ON  THE  SIX  CHIEF  MORBID  PULSE  TYPES  ;  AND  ON  THE 
METHODS  OF  TESTING  PULSES  AS  TO  TENSION. 

PAGK 

Preliminary  Description  of  the  Methods  for  Gauging 

Arterial  Tension  with  the  Finger        .        .72 

I.  The  obliterating  pressure — II.  The  test  for  successful 
obliteration — The  elementary  or  "bimanual"  method  of 
testing  the  nature  of  the  distal  pulse — The  <;  one  hand" 
method — III.  The  estimation  of  the  pressure  needed  for 
complete  obliteration  of  the  pulse. 

I.  The  Pulse  of  high  Arterial  Tension— II.  The  Pulse 
of  low  Arterial  Tension— III.  The  Pulse  in- 
Mitral  Regurgitation  (not  complicated  with 
Cardiac  Failure)— IV.  The  Pulse  in  Mitral 
Stenosis  (not  complicated  with  Heart 
Failure) 76-79 

V.  The    Pulse   of   Aortic    Regurgitation — Corrigan's 

Pulse,  or  Water-hammer  Pulse        .        .        .79 

The  tactile  characters  of  Corrigan's  pulse — Why  the 
patient's  hand  is  to  be  elevated  in  testing  for  this  pulse — 
The  visible  characters  of  Corrigan's  pulse — The  progress 
of  the  wave  (according  to  theory) — The  artery  between  the 
beats  (as  observed)— Arterial  elongation  and  tortuosity; 
the  locomotor  pulse. 

VI.  The  Pulse  of  Aortic  Valvular  Obstruction  .        .    83 


CHAPTER   VI. 

ASYNCHRONISM  AND  INEQUALITY  OF  THE  PULSES. 

The  Methods  of  Testing  for  Equality  of  Pulse-Beats, 
and  for  Identity  of  Pulse-Time  at  the  Two 
Wrists 85 


xiv  TABLE  OF  CONTENTS. 

PAGE 

How  to  Test  foe  Equality  of  the  Two  Radial  Pulses    85 

The  two  best  positions  for  the  patient's  hands — The  two 
methods  which  the  observer  may  adopt. 

How  to  Test  foe  Synchronism  in  the  Two  Pulses       .    87 

Check  Observations  Essential 89 


CHAPTER   VII. 

Capillary  Pulsation 90 

Elasticity  and  contractility  of  capillaries — Capillary 
pulsation  normally  absent — Pathological  occurrence  of 
capillary  pulsation — The  methods  for  detecting  capillary 
pulsation:  I.  The  "Tache"  method;  how  to  examine  the 
tache  for  pulsation— II.  The  "lip"  method— III.  The 
"nail  "method — Backward  or  regurgitant  capillary  pulsa- 
tion— Mode  of  distinguishing  the  backward  from  the 
onward  capillary  pulsation — Local  throbbing. 

CHAPTER   Till. 

VENOUS    PULSATION. 

I.  Venous  Pulsation  in  General 97 

Venous  pulsation  a  tergo,  a  fronte — Their  respective 
districts — True  or  direct,  and  false  or  communicated  venous 
pulsation — How  to  tell  one  from  the  other — The  onward 
venous  pulsation  and  its  causes — King's  method  of  demon- 
strating venous  pulsation — The  backward  or  regurgitant 
pulse  ;  its  causes. 

II.  Pulsation  in  Particular  Veins — Pulsation  in  the 

Jugulars  and  their  Tributaries     .  '     .  101 

Its  limits — Backward  jugular  pulsation,  and  backward 
jugular  rlow  (or  regurgitation} — Methods  for  ascertaining 


TABLE  OF  CONTENTS.  xv 

I-  U.K. 

the  presence  of  reflux  into  the  jugular  vein — The  subcostal 
pressure  method — The  presystolic  and  the  systolic  jugular 
pulsations  Varying  degree  of  jugular  distension  as  affect- 
ing the  pulsation — Inspection  of  the  episternal  notch  and 
of  the  supra-clavicular  fossa?. 

Backward  Pulsation  into  the  Inferior  Vena  Cava — 
Hepatic  Pulsation— Hepatic  Arterial  Pulsa- 
tion  105 


HOW  TO   FEEL   THE  PULSE 

AXD  WHAT  TO  FEEL  IX  IT. 


INTRODUCTORY. 

The  vast  importance  of  the  various  features  of  the 
pulse  was  guessed  by  physicians  long  before  the  dis- 
covery of  the  circulation,  but  it  has  only  been  fully 
demonstrated  within  the  memory  of  living  men.  It 
would  be  unfair  to  suppose  that  all  the  labour  which 
was  devoted  to  the  pulse  by  our  early  predecessors  in 
their  numerous  treatises  (Galen  alone  wrote  seven)  had 
been  wasted  and  barren  in  practical  results,  but 
the  amount  of  definite  information  to  be  extracted 
from  them  is  remarkably  small  and  buried  in  a  mass 
of  extravagant  assumption.  All  empty  surmises  have 
now  been  cleared  away,  and  the  clinical  uses  of  the 
pulse  narrowed  down  to  substantial  facts  connected 
with  it,  which  might  be  recorded  in  a  few  pages.  But 
the  value  of  these  clinical  facts,  few  as  they  may  be,  is 
in  advance  of  anything  dreamt  of  before,  and  is  the 
result  of  vastly  improved  anatomical  and  pathological 
knowledge.  It  is  already  capable  of  demonstration  by 
the  instrumental  methods  of  physiology,  and  we  are 
rapidly  approaching  a  stage  when  some  of  the  qualities 
of  the  pulse  will  find  a  mathematical  expression. 

A 


2  HOW  TO  FEEL  THE  PULSE. 

Meanwhile,  the  pulse  has  still  to  be  felt.     But  it  is  an 

operation  of  far  greater  importance  to  students  of 
medicine  nowadays  than  it  was  to  those  of  long  ago. 
Having  much  more  definite  objects  in  view  in  examin- 
ing the  pulse,  we  should  not  be  inferior  to  them  in  the 
attention  bestowed  upon  the  examination.  Moreover, 
since  all  experimental  results  are  dependent  upon  the 
conditions  of  the  experiment,  we  should  take  care  that, 
even  in  apparently  so  trivial  an  operation  as  feeling 
the  pulse,  we  use  the  best  available  method ;  in 
seeking  for  which  we  must  be  prepared  to  consider 
matters  in  some  detail. 


The  following  are  the  subjects  dealt  with  in  this 
book,  and  their  order : 

CHAPTER 

I.   The  pulse  and  the  practical  methods  for  its 

study. 
II.    Elementary  notions  on  the  physiology  of  the 
pulse. 
III.    The    chief    qualities    and    varieties    of    the 

normal  pulse. 
IV.   The  chief  abnormalities  of  the  pulse. 
V.   The  six  chief  morbid  pulse  types.      How  to 

test  the  pulse  as  to  tension. 
VI.   Asynchronism  and  inequality  of  the  pulses. 
VII.   Capillary  pulsation. 
VIII.   Venous  pulsation. 

The  matter  having  been  arranged  in  short  paragraphs 
with  special  headings,  an  index  has  not  been  deemed 
necessary  ;  but  a  short  glossary  of  the  terms  used 
formerly,  and  at  the  present  time,  has  been  appended. 


CHAPTER  I 

THE  PULSE  AXD  THE  PRACTICAL  METHODS 
FOP  ITS  STUDY. 


THE  PULSE :  CIRCUMSTANCES  AND  SITUATIONS 

FAVOURABLE  FOR  ITS  DETECTION. 

The  Visible  Pulse  and  the  Tangible  Pulse. 

In  common  language  "  pulse "  is  synonymous  with 
the  pulsation  at  the  wrist.  But  accuracy  demands  the 
prefix  of  "  radial "  to  this  particular  pulse  as  there 
are  various  situations  in  which  arterial  pulsation  can  be 
seen  as  well  as  felt ;  while  in  others  it  can  be  felt, 
though  not  seen.  When  we  speak  of  the  pulsation 
being  visible  or  palpable,  we  do  not  always  mean  that 
the  pulse  is  easily  seen  or  easily  felt.  Sometimes  pulsa- 
tion is  quite  obvious  and  even  obtrusive,  but,  as  a  rule, 
we  have  to  look  very  closely  for  any  evidence  of  move- 
ment in  the  situations  where  the  pulse  is  stated  to  be 
visible  ;  and  in  the  same  manner  we  must  feel  and  feel 
again  before  we  may  safely  say  that  we  are  unable  to 
discover  pulsation  where  pulsation  should  be  felt. 

Circumstances  Favouring  or  Hindering  the 
Detection  of  Arterial  Pulsation. 

No  device  except  position,  a  good  light,  and  the  me  of 
a  lens,  can  help  the  eye  in  perceiving  the  pulsation  of 


4  HOW  TO  FEEL  THE  PULSE 

an  artery  if  feeble.      Palpation,  on  the  other  hand,  is 
much   assisted   by   a    little    knowledge    and    previous 
practice.     Independently,  moreover,  of  personal  experi- 
ence, there  are  definite  conditions  assisting,  and  others 
that  hinder,  success  in  the  finger's  search  for  the  pulse. 
This  is  amply  borne  out  by  the  experience  of  surgeous 
in  various  operations  by  which  vessels  are  laid  bare, 
and  especially    in  those  where   an  artery  has  to  be 
found   and  tied.      The    operator,   after    exposing    the 
vessel  and  whilst  able  to  touch  it,  may  be  left  in  doubt 
as  to  its  identity,  or  may  even  mistake  it  for  some 
similar  structure,   ' '  because  unable  to  feel  in  it  any 
pulsation."     Yet,  before  the  operation,  the  vessel  may 
have  been  felt  to  'pulsate  when  pressed  against  lone  or 
muscle.     Similarly,  if  the  various  arteries  which  are 
easily  accessible  to  the  touch  be  explored,  it  will  be 
found  that  some  pulsate  much  more  distinctly  and  others 
less  so ;  that  those  arteries  which  are  supported  by  a 
firmer    back-ground    pulsate    more     powerfully    than 
others  ;   and,  lastly,  that  pulsation  is  most  strongly  felt 
in  those  which  are  in  proximity  with  bone.      On  the 
other  hand,  we  shall  become  acquainted  with  arteries 
so  superficially  placed  between  thin  skin  and  hard  bone 
immediately     underlying    the    skin,    that    the    finger 
almost  inevitably  obliterates  them  in  the  attempt  to 
feel    their   pulsation.      Arteries  thus  situated  do  not 
afford  very  good  opportunities  for  palpation,  in  spite 
of     their    superficial     position.      In     conclusion,     the 
favourable  conditions  are  : 

(1)  fair  size  of  the  artery  ; 

(2)  superficial  course  ; 

(3)  a  covering  of  thin  shin; 

(4)  a  supporting  surface  of  muscle,  cartilage,  dense 

fascia,  or  bone  (note  exception  which  follows). 


AND  WHAT  TO  FEEL  IN  IT.  5 

The  unfavourable  conditions  are  :  the  reverse  of  the 
preceding ;  and,  in  addition, — immediate  contact  of  an 
artery  with  underlying  bone,  especially  if  the  skin  (as 
over  the  temple)  be  tightly  stretched  over  the  bone. 
Bony  contact  becomes  then  relatively  a  disadvantage. 

I. 

Situations  in  which  Pulsation  may  be  Seen 
in  Lean  Subjects. 

In  the  young,  even  when  spare,  and  especially  in 
children,  the  arterial  pulses  are  hardly  ever  visible. 
At  most,  it  may  be  possible  to  perceive  the  beat  of 
the  radial. 

In.  old  'people,  and  especially  in  those  of  lean  habit, 
several  of  the  arteries  will  be  seen  to  pulsate.  This 
is  due  to  the  atrophy  of  muscles  and  of  other  tissues, 
or  to  the  senile  dilatation  and  elongation  of  the  arteries, 
or  to  a  combination  of  both. 

The  subjects  of  aortic  regurgitation  afford  specially 
favourable  opportunities,  their  pulsations  being  of 
exaggerated  type,  and  their  arteries  large,  whilst  the 
patients  themselves  are  generally  thin. 

Taking,  then,  the  most  favoitrablc  sidy'cct,  a  lean 
man,  advanced  in  years,  and  suffering  from  aortic 
valvular  incompetence,  the  following  arteries  would 
probably  be  seen  to  beat : — 

The  temporal  artery. 

The  anterior  and  the  posterior  temporals* 
The  angular. 
The  faded. 

Sometimes  the  transverse  facial. 

Sometimes   the   superior   and  inferior   ccronaries  (at 
their  origin). 


6  HOW  TO  FEEL  THE  PULSE 

The  occipital  (in  cases  of  baldness). 

The  external  carotid. 

Tin:  common  carotid, 

Sometimes  the  subclavian. 
,  Sometimes  the  innominate. 

The  long  thoracic. 

The  axillary. 

TJir  brachial  (especially  near  the  lend  of  the  elbov). 

The  radial. 

The  ulnar. 

The  dorsalis  indicis. 

Sometimes  the  abdominal  aorta. 

The  femoral  (in  the  upper  part  of  Scarpa }s  triangle). 

Sometimes  the  inferior  external  articular. 

Sometimes  the  malleolar  branches. 

Sometimes  the  anterior  peroneal. 

The  dorsalis  pedis. 

In  addition,  pulsation  may  be  seen  in  sundry  small 
subcutaneous  arteries,  and,  with  the  ophthalmoscope, 
(in  cases  of  aortic  reflux,  of  glaucoma,  and  sometimes 
in  Graves1  disease)  in  the  retinal  arteries. 

The  Influence  of  Position. 

In  the  case  of  several  of  the  arteries  enumerated 
above,  the  ease  with  which  pulsation  may  be  per- 
ceived varies  with  the  position  of  the  patient  or  of  the 
limb.  As  special  instances  should  be  mentioned,  the 
radial  at  the  wrist,  whose  beat  is  favoured  by  very 
slight  flexion,  or  at  least  by  the  absence  of  extension ; 
the  vlnar,  whose  pulsation  may  be  visible,  in  slight 
extension  only ;  and  especially  the  brachial,  which 
becomes  curved  into  a  prominent  loop  above  the  fold 
of  the  elbow  when  the  limb  is  flexed. 


AND  WHAT  TO  FEEL  IN  IT.  7 

II. 

Situations   in  which  the  Arterial  Pulse 
may  re  Felt  in  most  Surjects. 

With  the  exception  of  the  smaller  arteries,  which  are 
more  easily  seen  than  felt  by  the  average  observer, 
pulsation  is  perceptible  to  the  finger  in  all  arteries  in 
which  it  is  observed  by  the  eye. 

It  is  unnecessary  to  repeat  here  the  list  previously 
given,  which  applies  to  the  special  combination  of 
senility  and  of  emaciation  with  cardiac  disease. 

It  was  stated  that  during  health,  and  in  the  young 
and  sleek,  the  number  of  visibly  pulsating  arteries 
would  be  very  small.  This  is  not  the  case  with  the 
pulse  as  felt.  In  adults,  even  when  presenting  fairly 
thick  integuments,  the  beat  of  the  following  arteries 
may  usually  be  made  out  on  palpation  : — 

The  temporal  artery. 

The  anterior  and  posterior  temporals. 

The  occipital. 

The  facial. 

The  superior  and  inferior  coronaries. 

The  external  carotid. 

The  common  carotid. 

The  subclavian. 

The  innominate. 

The  axillary. 

The  brachicd  (in  its  entire  course). 

The  radial. 

The  ulnar  {with  difficulty). 

Sometimes  the  princeps  pollicis  and  the  digitals  (as  a 

general  pulsation  of  the  pidp). 
The  abdominal  aorta. 


8  HOW  TO  FEEL  THE  PULSE 

The  external  iliac. 

The  femoral  (in  the  upper  half  the  thigh). 

The  popliteal   {in   the   lower   part    of  the   popliteal 

space). 
The  posterior  tibial  (at  the  ankle-joint). 
Sometimes  the  anterior  peroneal. 
The  anterior  tibial  (just  above  the  ankle). 
The  dor  sails  pedis 
In  special  cases,  the  thyroids  (as  a  general  pulsation). 

The   Common  Pulses. 

Of  this   long  series  of  arterial  pulses  five  only  are 
utilised  in  every- day  medical  practice  : — 
The  temporal, 
The  faded, 
TJie  external  carotid. 
The  brachial, 
The  radial. 

III. 

The  Mode  of  Feeling  the  various  Pulses. 

The  mode  of  feeling  the  radial  pulse  will  be  pre- 
sently described  at  some  length,  and  the  best  way  of 
finding  the  other  four  will  be  thereafter  briefly  in- 
dicated. 

Among  the  remaining  pulses  that  of  the  eoronaries 
may  be  felt  from  the  outside,  against  the  teeth  as  a 
background ;  but  better  from  the  inside,  by  grasping 
the  thickness  of  the  lip  between  two  lingers. 

The  innominate  and  the  subclavian  beats  will  be 
felt  by  deeply  plunging  the  finger  into  the  cpisterncd 
notch  and  into  the  supra-clavicular  fossa  respectively. 

The  beat  of  the  subclavian  is  best  felt  where  the 


AND  WHAT  TO  FEEL  IX  IT.  9 

vessel  lies  on  the  surface  of  the  first  rib.  That  of  the 
innominate  is  not  readily,  except  in  special  case?,  dis- 
tinguishable from  the  strong  impulse  of  the  arch  of  the 
aorta  communicated  upwards. 

In  order  to  perceive  the  axillary  pulsation  the  arm 
must  be  raised.  The  vessel  can  then  be  felt  beating 
between  the  finger  and  the  head  of  the  humerus. 

For  the  detection  of  the  external  iliac  deep  pres- 
sure must  be  made  into  the  pelvis  above  Poupart's 
ligament. 

Rather  strong  pressure  is  also  required  in  the  case 
of  the  femoral,  if  the  thigh  be  muscular  or  very  fat. 
The  femur  forms  the  background. 

The  popliteal  pulse  is  more  readily  perceived  when 
partial  flexion  has  relaxed  the  tension  of  the  powerful 
muscles  among  which  the  artery  lies  concealed. 

The  easiest  way  to  feel  the  posterior  tibial  heat  is  to 
place  the  flat  of  the  finger  (whole  length)  in  a  vertical 
direction  just  behind  the  inner  malleolus.  Soft  pri  ssure 
of  the  phalanx  against  the  os  calcis  will  suffice. 

The  dorsalis  pedis  is  readily  felt  pulsating  when  the 
finger  is  applied  across  the  upper  part  of  the  arch  of 
the  foot.  Here  again  the  pressure  should  be  soft,  and 
the  flat  of  the  finger  should  be  used. 

IV. 

The  Seats  of  Election  for  a  Study  of  the  Pulse. 
The  Radial  Artery;  its  Advantages. 

In  most  of  the  situations  enumerated  above,  although 
the  pulse  may  be  recognised,  it  lies  too  deep  to  be 
successfully  studied.  For  this  purpose  the  seats  of 
election  are  the  face  for  the  temporal  and  the  facial 
arteries,    the  arm   for  the  brachial,  and  the   wrist  for 


ic  HOW  TO  FEEL  THE  PULSE 

the  radial.  The  first  two  vessels  are  almost  too  super- 
ficial. The  radial,  besides  being  much  larger,  possesses 
great  advantages  over  them  ;  and  over  the  brachial,  it 
has  that  of  personal  convenience. 

(1)  The  radial  presents  to  perfection  those  ana- 
tomical conditions  which  were  described  on  page  p.  4  as 
rendering  pulsation  easy  to  feel.  It  is  superficial,  and 
it  is  backed  by  a  bony  plane.  But  it  is  not  in  imme- 
diate contact  with  bone  at  that  part  where  the  pulse 
is  felt :  although,  nearer  the  wrist-joint,  it  lies  on  the 
styloid  process,  in  close  contact  with  its  surface. 

( 2 )  Another  great  advantage  of  the  radial  is  the 
considerable  length  (quite  three  inches)  over  which  it  is 
accessible  to  the  touch.  This  enables  the  observer  to 
feel  the  pulse  with  three  or  even  four  fingers. 


DESCRIPTION  OF  THE  PRACTICAL  METHODS 

FOR  THE  STUDY  OF  THE  PULSE. 

I. 
The  Method  of  Coubtdtg  the  Pulse. 

The  pulsating  artery  having  been  found,  the  next 
thing  (because  the  easiest)  is  to  count  its  beat.  This 
is  quite  distinct  from  the  operation  of  "  feeling  the 
pulse."  which  is  an  active  and  rather  difficult  inquiry. 
Here  the  touch  is  almost  entirely  passive.  The  points 
requiring  attention  are  : — 

(1)  To  keep  touch  with  the  pulse  by  a  gentle 
pressure,  so  that  none  of  the  beats  are  lost  to  the 
finger ; 


AND  WHAT  TO  FEEL  IX  IT, 


i  r 


£>tiT!Tftfla2< 


fatmcA  cf  Vlnm 


The  Radial  and  Ulnar  Arteries  at  the  Wrist  and  the  Superficial 
Palmar  Arch. 


[From  Gray's  "Anatomy,"  by  permission.) 


12  HOW  TO  FEEL  THE  PULSE 

(2)  To  moderate  the  pressure  of  the  finger,  so  that 
none  of  the  beats  are  suppressed  by  it ; 

(3)  To  avoid  mistaking  the  pulse-beat  of  the  finger 
for  that  of  the  patient's  radial  artery.  It  is  chiefly 
owing  to  the  reality  of  this  source  of  confusion  that 
counting  the  pulse  with  the  thumb  has  been  con- 
demned by  authors ;  the  beat  of  the  princeps  pollieis 
arteries  being  larger  than  that  of  the  digitals,  and 
rather  more  liable  to  be  felt  during  the  operation. 

Various  Sites  for  Counting  the  Pulse. 

For  a  simple  determination  of  the  pulse-rate  we  are 
not  limited  to  the  radial  artery;  any  artery  will  serve 
which,  being  superficial,  is  of  sufficient  size  to  enable 
us  to  securely  feel  the  beat.  An  opportunity  often 
occurs  of  counting  the  pulse  without  awaking  a  sleeping 
patient,  by  lightly  feeling  the  temporal  artery  where  it 
crosses  the  zygomatic  process.  This  method  is  espe- 
cially useful  in  children.  It  is  indispensable  in  cases 
of  great  restlessness  and  of  delirium,  and  in  chorea, 
where  the  arms  are  violently  thrown  about.  It  is  also 
indispensable  to  the  anaesthetist. 

Counting  the  Pulse  at  the  Carotid  and  at  the 

Heart. 

In  the  foregoing  remarks  it  has  been  assumed  that 
each  systolic  wave  reached  the  periphery ;  but  in  ex- 
haustion and  in  cardiac  disease  this  is  not  always  the 
case,  and  our  observation  must  be  a  direct' one — viz., 
by  palpation  or  auscultation  of  the  apex  beat,  after 
the  method  used  in  cases  of  apparent  death  for  de- 
termining whether  life  is  or  is  not  extinct.      Whenever 


AND  WHAT  TO  FEEL  IX  IT.  13 

the  pulse  has  been  taken  at  tit*:  heart,  let  the  fact  be 
noted. 

It  may  sometimes  be  convenient  to  take  the  pulse 
of  the  carotid  artery  (see  p.  33)  if  the  wrists  are  not 
available  or  their  pulse  too  weak,  but  especially 
during  auscultation  of  the  heart,  when  the  first  sound 
has  to  be  timed  from  an  artery  as  little  distant  from 
the  heart  as  possible.  In  some  diseases  this  beat 
is  so  prominent  that  the  pulse  may  be  counted  hy 
sight  and  without  touching  the  patient.  The  same 
facility  is  also  presented  by  the  heart  itself  when  the 
apex-beat  is  visible. 

Duration  of  the  Observation. 

Although  the  clinical  unit  of  time  is  the  minute,  our 
observations  are,  in  practice,  limited  to  fractions  of  a 
minute.  Hence  the  necessity  for  a  watch  beating  the 
second.  A  pulse  beating  regularly  may  be  safely 
••  taken "  in  fifteen  seconds,  less  accurately  in  ten. 
An  irregular,  and  especially  an  intermittent  pulse, 
requires  an  observation  lasting  at  least  thirty  seconds. 
In  cases  of  unusual  slowness  or  rapidity,  it  is  well  to 
make  two  separate  observations  of  half  a  minute  each, 
and  to  take  the  mean.  The  frequency  of  any  inter- 
missions, linked  beats,  or  small  beats,  should  be  ascer- 
tained by  separate  observations. 

Preliminary  Precautions. 

Since  the  pulse-rate  varies  with  movement,  change 
of  posture,  emotion,  thought,  and  speech,  it  is  well 
that  the  patient  should  be  at  rest,  supine,  silent,  and 
unexcited.  If  sitting  or  standing,  or  if  asleep,  the  fact 
should  be  noted.  It  will  often  save  time  to  count  the 
pulse   before  the  patient  has  moved  or   spoken ;  but 


i4  HOW  TO  FEEL  THE  PULSE 

with  some,  who  are  nervous,  the  physician's  approach 
is  enough  to  cause  excitement,  and  with  them  a  later 
count  would  probably  be  more  reliable. 

Where  the  pulse  is  very  rapid,  weak,  or  irregular, 
considerable  delicacy  of  touch — i.e.,  considerable  atten- 
tion— may  be  required  for  its  detection. 

Rules  to  be  followed  in  Counting  the  Pulse. 

Rule  I. — Determine  the  member  of  heats  in  fifteen 
seconds,  and,  multiplying  that  by  four,  record  the  rate 
per  minute. 

Rule  II. — If  the  pidse  should  be  irregular  in  rhythm, 
count  for  thirty  seconds,  or  else  for  two  separate  periods 
of  fifteen  seconds. 

Rule  III. — If  the  pidse  should  be  very  small  or  very 
slow,  or  faltering,  count  at  the  heart  and  record  the  fact. 
It  is  usefid  in  these  cases  to  record  also  the  rate  found  at 
the  wrist. 

Rule  IV. —  Whenever  possible,  let  the  patient  be  re- 
clining.    If  not  in  bed,  let  him  be  seated. 

Rule  V. — The  patient  should  be  silent  and  still, 
a  nd  judgment  must  be  used  in  selecting  a  moment  when 
no  excitement  prevails. 

II. 

The  Method  of  "  Feeling  the  Pulse." 

I.  General  Eules  relating  to  the  Attitude  of 
Body  and  Limb. 

The  operation  of  "  feeling"  or  "trying"  the  pulse 
must  always  be  kept  separate  from  the  operation  of 
"taking"  the  pulse.  It  claims  the  whole  mind. 
Simple  and  purely  mechanical  in  appearance,  it  is  a 


AND  WHAT  TO  FEEL  IN  IT.  15 

combined  effort  of  some  of  the  higher  functions,  and 
requires  skill  in  manipulation,  keenness  in  observation, 
and  other  qualities  which  wait  upon  long  practice  and 
experience.  Moreover,  the  data  obtainable  are  mean- 
ingless apart  from  a  knowledge  of  physiology  and 
pathology. 

That  which  has  previously  been  said  in  this  con- 
nection under  the  heading  of  counting  the  pulse  applies 
here  also,  and  need  not  be  stated  afresh.  In  all  things 
success  is  largely  dependent  upon  attention  to  small 
matters ;  and  details  such  as  the  patient's  attitude  and 
that  of  the  observer  have  their  importance.  The 
work  of  the  draughtsman,  of  the  musician,  of  the 
various  artists  and  artisans  is  severally  performed  to 
greatest  advantage  in  certain  positions  of  the  body,  of 
the  arm  and  of  the  hand.  Of  percussion  the  same  is 
true  and  it  is  also  true  of  feeling  the  pulse,  where  the 
touch  has  to  be  brought  to  bear  with  great  delicacy. 
In  most  of  the  instances  quoted  movements  of  vaiying 
difficulties  have  to  be  performed.  In  this  case  it  is  the 
absence  of  movement  that  needs  to  be  secured. 

Attitude  of  the  Body. 
(l)    The  Observer's  Attitude. 

Attitude  is  of  importance,  because  it  facilitates,  on 
the  part  of  the  observer,  the  appreciation  of  the  pulse  ; 
and  because  in  the  case  of  the  patient  it  influences  the 
pulse  itself. 

For  the  observer  almost  any  attitude  may  be  made  to 
answer  so  long  as  freedom  from  effort,  and  firmness  are 
ensured.  Certain  things  are  nevertheless  to  be  avoided. 
Too  great  a  distance  from  the  patient  will  necessitate 
stretching  the  arm  :  this  is  unfavourable.  Unsteadiness 
of  muscle  will  be  greater  in  proportion  to  any  fatigue  ; 


16  HOW  TO  FEEL  THE  PULSE 

— therefore  if  in  the  least  tired  the  observer  should 
be  seated  ;  the  body  no  longer  needing  to  support 
itself,  muscular  work  and  reflex  nervous  work  are 
thereby  spared. 

(2)    The  Patient's  Attitude. 

Many  patients  are  aware  that  their  pulse  is  influenced 
by  position.  A  fortiori  should  the  observer  not  lose 
sight  of  the  physiological  variations.  It  is  normal  for 
the  pulse  to  become  more  powerful  and  rapid  when  the 
reclining  posture  is  exchanged  for  the  sitting  or  espe- 
cially for  the  standing  position ;  in  feeble  invalids,  and 
even  in  nervous  and  weak  persons,  this  difference  may 
become  considerable.  Moreover,  putting  aside  the  direct 
influence  thus  exerted  on  the  pulse,  the  patient's  atti- 
tude may  have  some  bearing  on  the  success  of  the 
operation  of  feeling  the  pulse.  In  the  case  of  bedridden 
invalids  the  supine  position  is  the  most  natural  and  the 
best  because  the  most  supported.  When  not  bedridden, 
it  is  desirable  to  cause  the  patient  to  sit  dovn  if 
previously  standing.  This  will  afford  the  student  an 
opportunity  of  verifying  for  himself  the  accuracy  of 
the  statements  made  as  regards  variations  of  the  pulse 
in  changing  position.  Bearing  all  this  in  mind,  it  is 
well  to  establish  for  oneself  a  rule  to  take  pulse 
observations  on  patients  either  in  the  supine  or  in  the 
sitting  position.  If  this  practice  should  be  occasionally 
departed  from,  a  special  note  should  be  made  of  the 
fact. 

Attitude  of  the  Arm. 

Steadiness  Essential ;   how  Secured. 

Adequate  support  is  essential  for  the  observer's  arm 
as  well  as  for  the  patient's  arm. 


AND  WHAT  TO  FEEL  IX  IT.  17 

(!)    7"  'a  arm  is  liable  to  oscillations  arising 

from  the  heart's  action.  The  less  the  support,  so  much 
the  greater  the  instability  from  this  cause.  This  is  a 
first  reason  why  the  pulse  should  not  be  felt  at  arm's 
length.  Again,  for  the  same  reason,  accuracy  of  obser- 
vation is  out  of  the  question  under  the  influence  of  car- 
diac excitement  from  whatever  cause  ;  or  during  breath- 
lessness  induced  by  a  rapid  ascent.  In  practice  the 
observer's  arm  most  frequently  seeks  support  on  the 
bed,  or  on  the  table  ;  but  failing  any  mechanical  sup- 
port the  upper  arm  should  be  gently  steadied  against 
the  chest,  allowing  free  play  to  the  movements  of  the 
elbow  and  of  the  wrist. 

(2)  The  patient's  arm.  Support  in  this  case  is  yet 
more  important,  not  only  for  the  sake  of  steadiness, 
but  because  it  often  affords  the  simplest  means  fcr 
ensuring  absolute  relaxation  of  the  muscles  (see  p.  19). 
The  best  plan,  whenever  manageable,  is  to  cause  the 
entire  fore-arm  and  the  hand  to  rest  with  their  ulnar 
border  071  I  tabic,  the  hand  falling  over  in  very 

slight  pronation,  so  as  to  bear  on  the  semiflexed  joints 
of  the  4th  and  5th  fingers. 

Patient's  Arm  supported  by  the  Observer. 

Effectual  support  may  be  often  afforded,  according  to 
another  method,  to  the  arm  both  of  the  patient  and  of 
the  observer.  The  patient's  left  fore-arm  is  received 
on  the  observer's  left  hand  and  arm,  so  as  to  be  sup- 
ported almost  in  its  entire  length,  whilst  the  observer's 
left  elbow  is  steadied  against  the  side  of  the  chest. 

O 

Again,  when  the  pulse  has  to  be  felt  under  difficulties, 
for  instance  from  a  slight  distance,  or  across  the  bed,  as 
sometimes  happens  to  the  student  in  a  crowded  clinical 

B 


IS  HOW  TO  FEEL  THE  PULSE 

class,  the  observer's  grasp  of  the  patient's  wrist  may  both 
give  and  take  a  measure  of  support.  In  an  attitude 
such  as  this  the  larger  muscles  come  into  play  and 
much  delicacy  of  touch  cannot  be  expected.  An 
observation  taken  under  conditions  so  adverse  cannot  be 
a  good  one,  though  it  may  not  be  absolutely  worthless. 

Muscular  Relaxation  Essential. 
(1)  In  the  Observer. 

The  first  requisite  for  fine  sensory  appreciation  is 
freedom  from  muscular  strain.  Any  performance 
requiring  skill  is  rendered  difficult  to  beginners  by 
misplaced  energy.  Their  good  intentions  run  into 
physical  force.  Yet  of  the  latter  very  little  is  really 
needed.  In  this  special  case,  as  the  words  "  feeling  the 
pulse  "  imply,  we  are  dealing  with  a  sensory  rather  than 
a  muscular  function. 

Adequate  support  may  be  said  to  be  the  cure  for 
the  muscular  anxiety  of  all  beginners.  This  is  one  of 
the  chief  reasons  why  any  delicate  work,  be  it  of  the 
hands  as  in  fine  dissection,  or  of  the  eye  as  in  micro- 
scopic work,  or  of  the  ear  as  in  auscultation,  demands 
a  firm  basis.  An  excellent  instance  in  point  is 
afforded  by  the  patient's  strain,  to  which  we  shall 
presently  refer. 

(2)  In  the  Patient — Management  of  the  Patient's 

Wrist. 

The  chief  difficulty  arises  in  many  cases  from  the 
nimia  diligentia  of  the  too  willing  patient.  Com- 
plete muscular  relaxation  is  needed :  fik'st,  because 
muscular  effort  affects  the  pulse  (a  source  of  error 
which  might  be  overlooked) ;  secondly,  because,  under 
effort,    the    leaders    will    stand    out    at     the     wrist, 


AND  WHAT  TO  FEEL  IN  IT.  19 

placing  the  radial  artery  out  of  reach.  Among 
hospital  patients  the  student  will  recognise  two  types 
differing  in  the  presence  or  in  the  absence  of  energy. 
The  feeble  and  timid  subjects  usually  allow  the  hand 
to  lie  on  the  bed ;  this  is  generally  the  case  with 
female  patients.  Even  they,  however,  if  nervous,  will 
involuntarily  raise  the  wrist  in  opposition  to  our 
purpose,  though  they  may  allow  the  elbow  to  rest 
supported  on  the  bed.  On  the  other  hand,  the  rough 
working  man  almost  always  presents  his  wrist,  that  is, 
raises  his  arm  and  stiffens  his  powerful  muscles  in 
moderate  supination. 

To  such  wrists  the  employment  of  any  force  is  worse 
than  useless ;  it  will  only  aggravate  the  tension.  The 
quickest  method  is  to  seemingly  give  up  our  attempt, 
to  drop  the  stiffened  arm,  and  to  refuse  it  again  if  it 
be  raised  from  the  bed.  When  the  patient  has  at  last 
allowed  the  hand  to  remain  at  rest,  the  wrist  is  to  be 
clasped  with  great  gentleness  by  the  observer's  hand, 
whose  fingers  are  then  applied  to  the  pulse.  At  the 
same  time  the  thumb  glides  softly  from  the  back  of 
the  radius  to  the  back  of  the  carpus,  where  a  gradual 
and  light  pressure  will  almost  at  once  succeed  in  fully 
flexing  the  wrist.  This  being  effected,  the  spasm  of 
the  whole  limb  relaxes  and  the  pulse  is  under  control. 

The  Attitude  of  the  Hand. 

Before  proceeding  further  we  have  two  questions  to 
consider : 

(A)  Which  Pulse  to  hold? 

As  a  constant  rule  that  of  the  opposite  side  to  that  of 
the  hand  which  feels.  This  is  the  only  method  which 
the  learner  can  conveniently  practise  on  himself.      It 


20  HOW  TO  FEEL  THE  PULSE 

may,  however,  be  desirable  to  check  the  results  of  one 
position  by  those  of  the  reverse  one ;  and  to  feel  the 
patient's  left  pulse  with  the  left  hand  and  his  right 
pulse  with  the  right  hand,  in  addition  to  the  previous 
experiment. 

(B)  Which  Hand  to  Use? 

It  matters  very  little  whether  the  right  hand  or  the 
left  hand  be  used.  There  is  obvious  advantage  in 
training  both  if  possible.  Most  observers  however  will 
fall  into  a  one-sided  habit,  which  probably  will  enable 
them  to  secure  greater  delicacy  of  touch  at  the  expense 
of  a  little  freedom.  This  may  have  the  advantage 
that  the  untrained  hand  can  be  brought  to  bear  in  cases 
of  doubt,  and,  like  the  consultant's  opinion,  add  new 
light  through  its  comparative  strangeness  to  the  case. 

The  Attitude  of  the  Observer's  Hand. 

Here,  also,  as  far  as  the  hand  is  concerned,  the  best 
position  is  depicted  in  the  illustration. 

As  previously  stated,  the  observer's  right  hand 
should  hold  the  patient's  left  pulse  and  vice  versd.  It 
will  be  noticed  that  the  observer's  thumb  is  applied  to 
the  bach  of  the  lower  end  of  the  radius :  this  arches  his 
wrist  and  raises  the  second  phalanx  from  the  patient's 
wrist. 

A  modification  of  the  same  method  consists  in  pass* 
ing  the  thumb  round  the  wrist  in  such  a  manner  that 
its  extremity  faces  that  of  the  fingers ;  or  the  thumb 
remaining  unemployed  over  the  back  of  the  metacarpus, 
the  ball  of  the  thumb  and  of  the  little  finger  may  be 
pressed  against  the  back  of  the  ulna.  In  both  these 
methods  the  hand  encircles   the   wrist,    and   the   last 


AND  WHAT  TO  FEEL  IX  IT. 


21 


phalanx   bears,  not   with   its   tip.  but   with   its   entire 
length,  on  the  region  of  the  radial  beat. 


Fig.  2. 


The  "  Superi  ition  of  hand  to  be  adopted  in  feeling  the 

pulse.     In  this    illustration  the    index  finger  alone  is  show 
the  act  of  feeling.     The  median  and  annular  fingers  are  engaged 
in  compressing  the  artery. 


Although  it  is  best  to  adopt  the  hand  position   first 
named,  it  is  desirable   for   the    beginner  to    try   every 


22 


HOW  TO  FEEL  THE  PULSE 


variety  of  position ;   and   it    is   good   at   any  time  to 
test  doubtful  results  by  another  method. 

The  "Superior"  and  the  "Inferior"  Position 
of  the  Hand. 

When  feeling  his  own  pulse  the  student  will  observe 
that  his  finger  tips  may  be  made  to  approach  it  either 

Fig.   3. 


The  "Inferior"  Position  of  hand. — The  right  hand  is,  in  this 
illustration,  applied  to  the  left  wrist  (as  when  the  observer  is  taking 
his  own  pulse).  If,  however,  the  patient's  right  pulse  be  felt  with 
the  right  hand,  the  index  finger  will  then  occupy  the  usual 
position,  near  the  wrist.  The  fingers  are  shewn  with  the  flat  of 
the  pulp  applied  to  the  artery,  in  the  position  most  favourable 
for  feeling  the  pulse. 

with  the  palm  of  the  hand  turned  upwards — or  with 
the  palm  turned  downwards.  The  position  which  has 
been  described  (see  Fig.  2)  represents  the  first  of  these 


AND  WHAT  TO  FEEL  IX  IT.  23 

two  methods.  I  am  in  the  habit  of  terming  this  the 
u  Superior  "  the  other  being  the  "Inferior"  method 
(see  Fig.  3).  These  names  have  reference  to  the  rela- 
tion of  the  fingers  to  the  outer  border  of  the  radius. 

The  superior  position  is  the  one  to  be  adopted  in  all  rases 
by  the  student,  except  (for  convenience)  when  trying 
his  own  pulse. 

The  Arrangement  of  the  Fingers,  and  their 
Relation  to  the  Wrist. 

The  simplest  case,  in  which  one  finger  only  is  applied 
to  the  pulse,  requires  no  special  description.  Most 
observers  prefer  to  use  two  or  even  three  fingers.  It  is 
to  this  case  that  our  remarks  specially  apply. 

The  Distal  Position  and  the  Proximal  Position 
of  the  Index  Finger. 

(1)  If  we  imagine  that  the  observer's  right  hand  is 
feeling  the  patient's  left  radial  pulse  from  above,  whilst 
his  thumb  rests  on  the  back  of  the  wrist,  the  employed 
fingers  will  be  arranged  in  the  following  order: — The 
index  nearest  the  patient's  hand;  the  median,  in  an 
intermediate  position;  the  annular  nearest  the  heart. 
The  same  arrangement  will  prevail  if  the  observer's 
left  hand  tries  the  patient's  right  pulse. 

( 2 )  If,  on  the  contrary,  the  right  pulse  be  felt  from 
above  by  the  observer's  right  hand,  the  situation  of 
the  fingers  will  be  reversed — viz.,  the  index  will  be 
nearest  the  heart ;  and  the  annular,  nearest  the 
hand. 

The  second  arrangement  is  preferred  by  some.  But 
the  first  arrangement  has  the  support  of  considerable 
antiquity  and  appears  to  be  not  less  excellent.      It  is 


24  HOW  TO  FEEL  THE  PULSE 

decidedly  more  convenient  in  controlling  a  stiff  wrist, 
(see  p.  19).  Beyond  this  there  is  really  no  superiority, 
worth  arguing  here,  of  one  over  the  other  method.  On 
the  other  hand,  the  advantage  to  be  obtained  from 
uniformity  in  the  method  will  repay  us  for  strictly 
adhering  to  one  or  the  other  plan. 

Let  it  be  understood  that  the  foregoing  refers  ex- 
clusively to  the  "superior  method,"  which  alone  is 
recommended  to  the  beginner  for  reasons  which  need 
not  be  set  forth  at  length. 

The  Exact  Spot  where  the  Finger  should  be  Placed. 

The  distal  finger,  whichever  it  be,  should  be  placed 
on  the  artery  immediately  above  the  base  of  the  styloid 
process  of  the  radius.  The  other  two  fingers  (if  three 
be  used)  would  be  arranged  in  loose  contact  with  each 
other.  For  the  special  purpose  of  estimating  tension 
it  is  desirable  to  separate  the  two  centrally  placed 
lingers  by  an  interval  from  that  more  distally  placed 
(see  Fig.  2),  To  this  arrangement  reference  will  be 
made  later  on. 

The  Inclination  of  the  Fingers. 

The  direction  of  the  distal  phalanges  as  they  rest 
on  the  pulse  claims  a  moment's  attention.  According 
as  the  hand  and  fingers  are  more  or  less  arched  above 
the  wrist,  the  last  phalanx  of  each  finger  will  be  more 
or  less  vertically  applied  to  the  long  axis  of  the  radius 
and  of  the  artery.  The  absolutely  perpendicular  position 
(see  Figs.  -1,  5,  G)  is  not  desirable  unless  it  have  for  its 
object  the  occlusion  of  the  artery  by  pressure.  For 
the  'purpose  of  fine  feeling  a  slight  inclination  {obliquity) 
of  the  phalanx  is  desirable.      This  brings  a  very  sensi- 


AND  WHAT  TO  FEEL  IX  IT.  25 

tive  portion  of  the  pulp  (not  that  nearest  the  nail) 
to  bear  on  the  artery,  namely,  that  portion  which 
generally  meets  the  pulp  of  the  thumb  in  the  simple 
movement  of  opposition.  This  portion  seems  specially 
adapted  for  such  tactile  explorations  as  require  to  be 
combined  with  slight  pressure ;  whereas  at  the  ex- 
treme tip  of  the  pulp  there  exists,  it  is  true,  yet 
greater  delicacy  of  surface-touch,  but  one  easily  blunted 
by  the  slightest  pressure. 


II.  The  Exploration  of  the  Pulse. 

The  fingers  having  been  securely  placed  over  the 
beating  artery  the  exploration  of  the  pulse  begins. 
This  consists 

A.  of  the  application  of  a  varying  amount  ofpres 
to  the  artery ; 

B.  of  a  careful  notice  of  the  behaviour  of  the  pulse 
under  each  degree  of  pressure  : 

C.  of  a  manipulation  (or  "fingering")  of  the  pulse. 

A.  The  Degrees  of  Pressure  to  be  Applied. 

The  amount  of  pressure  may  of  course  be  varied 
almost  indefinitely ;  but  there  are  three  degrees  which 
it  is  convenient  to  single  out  from  the  rest,  namelv. 

1.  Tlie  lightest  possible  touch  of  the  finger; 

2.  The  medium  pressure. 

3.  The  obliterating  pressure. 

These  three  varieties  are  shown  in  the  accompanying 
illustrations  (taken  from  Dr.  Douglas  Powell's  dia- 
gram), which  do  not  however  depict  the  proper  attitude 
of  the  fingers,  but  simply  the  effect  of  their  pressure 
on  the  artery. 


26 


HOW  TO  FEEL  THE  PULSE 

Fh..  4. 


Shewing  light  pressure. 
In  Fig.  4  there  is  bare  contact  between  the  finger  and  the  artery. 
The  latter  is  felt,  but  is  not  compressed.     Very  little  pulsation  is 
perceived. 


Fin. 


Shaving  medium  pressure. 
In   Fig.   5   the  finger  is  applied  with   moderate  force,  and  the 
diameter  of  the  artery  at  that  spot  is  reduced  by  one-third,  to  one- 
half.     It   is  this  degree   of  pressure  which  yields   the   maximum 
sensation  of  arterial  beat. 

Fig.  6 


Shewing  forcible  pressure. 
In  Fig.  6  the  finger  bearing  upon  the  artery  has  flattened  it. 


AND  WHAT  TO  FEEL  IN  IT.  27 

The  deep  pressure  is  made  with  the  object  of  ascer- 
taining the  atnovnt  of  force,  or  the  weight,  which  will 
completely  abolish  pulsation.  This  is  one  of  the  most 
important  parts  of  a  systematic  exploration  of  the 
pulse.  The  force  required  in  order  to  extinguish  the 
pulse  will  be  found  to  vary  within  very  wide  limits  in 
different  individuals,  and  at  different  times. 

We  shall  see  later  on  that  a  combination  of  deep  and 
of  medium  pressure  is  to  be  employed  whenever  we 
desire  to  ascertain  that  the  obliterating  pressure 
exerted  by  one  or  by  two  fingers  has  effected  its 
purpose.  In  this  case  the  other  finger  is  pressed 
moderately  firmly  at  a  point  nearer  the  wrist,  in  search 
of  any  vestige  of  pulsation,  as  shown  in  Fig.  2. 

How  to  Regulate  the  Pressure. 

Of  the  three  degrees  of  pressure  the  third  alone 
represents  a  definite  result ;  it  is  a  procedure  requiring 
strength  rather  than  skill.  The  other  two  degrees 
cannot  be  defined  with  precision  (since  they  must 
vary  with  each  individual  strength  of  pulse),  but  must 
be  left  to  personal  judgment  and  experience.  To 
those  gifted  with  delicate  touch,  or  trained  to  artistic 
pursuits,  any  suggestions  are  almost  superfluous ;  but 
some  beginners  will  find  assistance  in  the  following 
hints  : 

1.  On  first  applying  the  fingers  exert  rather  firm 
pressure,  so  as  thoroughly  to  feel  the  beat ; 

2.  Almost  immediately  relax  the  pressure,  but  let  this 
be  done  gradually  so  that  the  finger  is  gently  raised 
by  the  artery  or  would  even  seem  to  lift  the  artery 
with  it ; 

3.  By  degrees  reduce  the  pressure  to  the  utmost,  so 
that  bare  contact  remains  with  the  skin  covering  the 


28  HOW  TO  FEEL  THE  PULSE 

artery.  This  is  the  first  degree.  After  observing  the 
pulse  at  this  stage, 

i.  Proceed  now  to  use  active  exploring  pressure  and 
determine  the  amount  which  gives  the  maximum 
pulsation.      This  is  the  second  or  medium  degree  ; 

5.  Lastly  gauge  the  resistance  of  the  pulse  by  using 
as  much  pressure  as  will  obliterate  the  artery. 

X.B. — A  quick  and  most  practical  way  of  gain  nig  an 
idea  of  the  procedure  to  be  followed)  consists  in  getting  in 
succession  two  or  three  senior  fellow-students  to  fed  one's 
own  pulse.  The  different  sensations  conveyed  to  the  wrist 
by  different  observers  will  be  more  suggestive  than  the  most 
elaborate  descriptions. 

B.  The  Behaviour  of  the  Pulse  under  Varying 

Pressures. 

This  is  the  tale  which  each  artery  under  observa- 
tion must  tell  for  itself.  The  special  points  which 
have  to  be  appreciated  and  described  are  indicated  in 
Chapter  II. 

C.  The  Manipulation,  or  "  Fingering,"  of  the  Pulse. 

Hitherto  the  fingers  have  been  stationary,  and  the 
presence  or  absence,  the  degree  or  quality,  of  the 
arterial  beats  have  been  their  object  of  study.  The 
present  heading  refers  to  a  separate  inquiry,  in  con- 
ducting which,  movements  of  the  fingers  must  be  combined 
with  their  tactile  function.  It  is  no  longer  the  pulse- 
beat  alone,  but  also  the  artery  itself,  during  the  interval 
between  the  beats,  or  whilst  obliterated  by  pressure,  which 
comes  under  observation.  Arteries  differ  greatly  in 
their  shape,  size,  and  other  qualities,  as  will  be  seen 
hereafter  (see  p.  58).  Some  of  their  changes  being 
of  much  importance,  we  should    avail  ourselves  of  the 


AND  WHAT  TO  FEBL  IX   IT.  29 

information  concerning  them  which  may  be  gained  by 
the  two  simple  movements  of  the  fingers  about  to  be 
described  : 

A  gliding  or  rubbing  movement  across  the  axis  of  the 
arti  ry. 

A  similar  movement  conducted  along  the  course  of  the 

it  I . 

By  the  first  we  learn  whether  the  artery  has  much 
or  little  thickness,  hardness  and  elasticity. 

By  the  second  we  are  informed  as  to  the  degree  of 
smoothness,  of  straight ness,  or  of  tortuosity;  and  the 
elasticity  of  the  vessel  is  further  tested. 

In  addition  to  this  form  of  manipulation,  which 
addresses  itself  to  the  arterial  walls,  there  is  a  finer 
fingering  of  the  pulse  itself  of  which  the  systematic 
pressure  applied  to  the  artery  is  but  the  coarser  mode. 
It  can  be  more  easily  hinted  at  than  described.  It  is 
a  touch  which  tests  the  qualities  of  the  pulse  through 
and  through,  sometimes  playing  at  the  surface,  some- 
times sounding  as  it  were  the  depth  of  the  arterial 
stream,  sometimes  bearing  with  full  weight  against  the 
force  of  the  pulse  wave,  sometimes  pursuing  it  in  its 
fall  and  floating  up  with  its  rise,  a  touch  as  soft  and 
as  keen  as  that  of  the  blind, — in  short  a  touch  with  a 
mind  in  it. 


METHODS  FOR  RAPIDLY  FINDING   THE  PULSA- 
TIONS OF  SOME  OTHER  ARTERIES. 

HOW  TO  FIND  THE  BEAT  OF  THE  FACIAL  AfiTERY, 

In  this  case  the  distal  phalanx  (with  nail  downwards) 
is  brought    to   bear  from   above   and   from   the   front 


30  HOW  TO  FEEL  THE  PULSE 

against  the  rounded  border  of  the  patient's  inferior 
maxilla,  immediately  anterior  to  the  masseter  muscle. 
Firm  pressure  must  be  made  at  first,  which  will  cause 
the  edge  of  the  bone,  and  perhaps  the  arterial  groove, 
to  be  felt.  Pressure  is  then  relaxed  so  that  the  ringer 
remains  only  in  distant  touch  with  the  bone,  and  lies 
with  hardly  any  weight  on  the  skin.  The  arterial  beat 
will  at  once  be  perceived. 

The  facility  with  which  this  artery  is  obliterated  is 
very  great ;  indeed  it  is  more  apt  than  the  temporal  to 
be  unintentionally  compressed  because  although  the 
skin  is  thicker  and  better  provided  with  subcutaneous 
fat,  the  artery  itself,  lying  in  a  groove,  is  in  hard 
bony  contact  for  almost  half  its  circumference. 

The  artery,  as  it  lies  in  a  loose  curve  over  the 
slightly  convex  horizontal  surface  of  the  bone,  in  the 
angle  formed  by  the  masseter  and  the  buccinator 
muscles,  affords  an  excellent  opportunity  for  some  pulse 
observations. 

How  to  Find  the  Beat  of  the  Temporal  Artery. 

It  is  often  necessary  to  find  this  beat  quickly  in  an 
emergency,  or  during  the  administration  of  anaesthetics. 
Every  student  should  be  trained  to  do  this  successfully; 
and  with  that  view  the  following  directions  will  be 
found  useful. 

(1)  Whilst  you  stand  behiud  the  patient's  head,  or 
at  his  side,  approach  the  zygomatic  process  from  below 
with  the  pulp  of  the  median  finger  turned  upwards. 
The  finger  is  to  be  gently  pressed  between  the  condyle 
of  the  jaw  below,  and  the  zygoma,  the  side  of  the 
finger  just  touching  the  tragus.  Having  made  firm 
pressure  so  as  to  feel  the  border  of  the  bone,  gradually 


AND  WHAT  TO  FEEL  JN  IT. 


31 


reduce  the  pressure  so  that  the  bone  is  only  distantly- 
felt.  At  this  sta^e  the  artery  will  probably  be 
detected.      This  is  the  inferior  method. 


Fig.  7. 


J  .Vaifc 


Illustrating  the  anatomy  of  the  External  Carotid,  Temporal, 
Anterior  and  Posterior  Temporal,  Facial,  Transverse  Facial, 
Coronary,  Angular  and  Occipital  Arteries  ;  and  the  situations  in 
which  their  pulsations  may  be  felt. 

{From  Grays  "Anatomy,"  by  permission.) 


32 


HOW  TO  FEEL  THE  PULSE 


(2)  Exactly  analogous  is  the  superior  method  which 
finds  the  artery  as  it  crosses  the  upper  edge  of  the  zygo- 
matic process.  In  this  case  additional  facility  is  given 
by  the  fact  that  the  further  course  of  the  artery  is 
superficial,  and  easily  felt. 


Fro.  8. 


Maiiai  Ilcczrrciie. 


Illustrating  the  course  of  the  Brachial  Artery  at  the  bend  of  the 

elbow. 
{From  Gray's  "Anatomy"  by  permission.') 

Either  of  these  two  methods  is  to  be  preferred  to 
the  attempt  to  feel  the  arteiy  on  the  dorsum  or  surface 
of  the  zygoma.  Here  a  very  nice  adjustment  of  pres- 
sure is  necessary.  The  artery,  being  quite  superficial 
and  immediately  backed  by  bone  without  any  padding, 
is  readily  obliterated  in  the  effort  to  find  it. 


AND  WHAT  TO  FEEL  IN  IT.  33 

HOW    TO    FIND    THE    CAROTID    BEAT. 

The  pulsation  of  the  common  carotid  will  be  found 
with  great  ease,  on  pressing  the  tip  of  the  finger  back- 
wards towards  the  spine,  at  or  above  the  level  of  the 
cricoid  cartilage,  and  close  to  its  side.  The  line 
passing  from  the  horn  of  the  hyoid  bone  to  the  tragus 
roughly  corresponds  to  the  course  of  the  external  carotid^ 
the  beat  of  which  is  readily  felt,  although  the  pressure 
of  the  finger  is  not  opposed  by  any  bony  surface. 

HOW    TO    FIND    THE    BRACHIAL    PULSE. 

Unusually  good,  and  in  some  ways  unique,  oppor- 
tunities for  studying  the  pulse  are  afforded  by  the 
brachial  artery.  The  procedure  is  so  simple  that  it 
hardly  calls  for  a  special  description.  The  artery  is 
accessible  along  the  entire  leDgth  of  the  upper  arm. 
The  tip  of  the  finger  is  thrust  under  the  biceps  from 
its  inner  side,  so  as  gently  to  lift  the  muscle  with  the 
dorsum  of  the  phalanx,  whilst  the  pulp  exerts  pressure 
on  the  artery  and  on  the  humerus  behind  the  artery. 


CHAPTER  II. 

ELEMENTARY  NOTIONS  OX  THE  PHYSIOLOGY 
OF  THE  PULSE. 


In  tliis  chapter  it  is  proposed  very  briefly  to  consider 
the  following  subjects  for  study  : — 

The  Structure  of  Arteries. 

The  Pulse -wave. 

The  Intra-arterial  Blood-pressure. 

The  Arterial  Tension. 

The  Structure  of  Arteries. 

All  arteries  agree  in  possessing — (1 )  An  epithelioid 
membrane  supported  by  an  clastic  membrana  propria. 
This  is  the  tunica  intima.  (2)  A  more  or  less  spirally 
arranged  layer  of  plain  muscular  fibres,  supported  by  a 
connective-tissue  layer.  This  is  the  tunica  media. 
(3)  A  connective-tissut  membrane,  consisting  mainly  of 
longitudinal  bundles  and  of  a  varying  proportion  of 
elastic  fibres.  This  is  the  tunica  externa,  which  is 
continuous  with  the  connective  tissue  surrounding  the 
artery. 

In  the  larger  arteries  (as  such  we  may  reckon  the 
radial)  the  tunica  intima  possesses  a  much  thicker  mem- 
brana propria,  described,  owing  to  the  cribriform  arrange- 
ment of  its  elements,  as  fenestrated  membrane;  and  this 
membrane,   when  free  from  distending  pressure,   falls 


HOW  TO  FEEL  THE  PULSE.  35 

into  longitudinal  wrinkles,  seen  in  transverse  sections 
as  festoons. 

The  media  is  thick,  and  consists  of  alternating  mus- 
cular and  elastic  planes  united  by  a  small  quantity  of 
white  connective  tissue.  The  arrangement  of  the 
muscular  fibres  is  circular  ;  that  of  the  elastic  elements 
chiefly  longitudinal. 

The  externa  contains,  besides  connective  tissue,  a 
quantity  of  elastic  fibres  and  a  few  plain  muscular 
fibres.      The  arrangement  is  chiefly  longitudinal. 

The  nutrient  vessels  and  the  nerves  ramify  in  the 
externa  and  penetrate  into  the  media,  but  not,  so  far 
as  known,  into  the  intima. 

The  larger  arteries  generally  possess  in  addition  a 
tough  fibrous  sheath  containing  but  little  elastic  tissue. 

The  Cardiac  Systole  and  the  Pulse- wave. 

The  systolic  charge  of  the  left  ventricle,  in  the  adult,  is 
6  oz.  or  may  vary  from  3  to  5  oz.  This  amount  is  at 
each  beat  of  the  heart  injected  with  powerful  effort 
into  the  aorta.  The  latter,  already  containing  blood, 
opposes  some  resistance  to  the  raising  of  the  semilunar 
valves.  The  rising  intra-ventricular  pressure  soon 
disposes  of  this  obstacle  and  of  the  resistance  offered 
to  further  distension  by  the  aortic  coats  themselves  ;  and 
a  powerful  spasm  empties  the  heart. 

Two  events  occur  in  the  arterial  system  as  a  result 
of  the  systole  of  the  left  ventricle  : 

(1)  The  aortic  contents  are  increased,  and  the  aortic 
stream  accelerated;  and 

(2)  A  wave  of  pressure  is  sent  through  the  whole  arterial 
system. 

Inasmuch  as  the  healthy  arterial  coats  are  yielding, 
the  wave    of  increased  pressure  produces    a  wave  of 


36  HOW  TO  FEEL  THE  PULSE 

dilatation  of  the  arterial  walls,  visible  to  the  naked 
eye,  and  appreciable  to  the  touch.  The  pulse  as  it  is 
felt  at  the  wrist  is  connected  with  the  passage  of  this 
wave. 

Velocity  of  the  Pulse-wave. 

The  velocity  of  the  wave  is  influenced  by  various 
circumstances,  but,  at  its  lowest,  is  still  very  great 
(it  varies  from  16*5  to  33  feet  per  second). 

Velocity  of  the  Blood-stream. 

Meanwhile  the  blood  travels  in  its  arterial  bed  at 
much  slower  rates  (twenty  to  thirty  times  less  rapidly). 

If  therefore,  the  radial  artery  be  divided,  each  spirt 
(which  now  takes  the  place  of  a  pulse)  of  the  arterial 
jet  will  belong  to  the  ventricular  systole  which  shall 
have  occurred  within  the  same  third  of  a  second ; 
but  the  jet  itself  consists  of  blood  which  has  left  the 
heart  many  seconds  earlier. 

The  velocity  of  the  blood-current  varies  greatly  in 
the  various  sections  of  the  vascular  system.  The 
following  values,  taken  from  Gerald  Yeo's  "Physiology,"* 
will  give  some  idea  of  these  variations,  and  from  them 
an  estimate  may  be  formed  of  the  average  rate  of  pro- 
gress of  the  blood. 

Rapidity  of  Blood-stream. 


Mm.  per  Second. 

Near 

the  Valves  of 

Aorta, 

—while  the  ventricles 

are 

contracting 

. 

..... 

1200 

In  the  Descending 

Aorta 

..... 

300-600 

>> 

Carotid      . 

. 

..... 

205-357 

>> 

100 

j» 

Metatarsal 

. 

..... 

57 

>> 

Arterioles 

• 



50 

*  Edition  1884,  pp.  252,  253. 


AND  WHAT  TO  FEEL  IX  IT.  37 

Mm.  per  Second. 

In  the  Cap&ari •'> 

,,       Venous  Radi  ..... 

„        /Small  Veins  on  dorsum  of  hand 

„       Vena  Cava 200 

The  distinction  between  pulse-wave  and  blood-stream 
having  been  made  clear,  the  latter  need  not  be  again 
referred  to,  and  subsequent  remarks  will  exclusively 
apply  to  the  pulse-wave  or  pressure-wave. 

Length  of  the  Pulse-wave. 

The  length  of  the  pulse-wave  is  variously  estimated 
by  physiologists  at  2  to  6  metres.  Prof.  Gerald  Yeo* 
says  :  "  Knowing  the  rate  at  which  the  pulse  travels 
(10  m.  per  sec.)  and  the  time  it  takes  to  pass  any 
given  point  (J  sec),  its  length  may  be  calculated  to  be 
about  o  metres,  or  about  twice  as  long  as  the  longest 
artery.  Thus  the  pulse-wave  reaches  the  most  distant 
artery  in  one-sixth  of  a  second,  or  about  the  middle  of 
the  ventricular  systole,  and  when  the  wave  has  passed 
from  the  arch  of  the  aorta,  its  summit  has  just  reached 
the  arterioles."  "  Hardly  more  than  J  to  J  of  a  second 
lapses  between  the  beat  of  any  two  arteries,  however 
distant  from  each  other.'' 

The  Pulse-wave,  and  the  Sphygmogram. 

A  wave  travelling  at  the  rate  of  20  to  30  feet  a 
second  and  occupying  a  length  equal  to  that  of  two  or 
three  men  : — this,  then,  is  the  pulse-wave.  Neither  from 
a  casual  feel,  nor  from  the  sphygmograph,  had  we  gained 
any  idea  of  these  magnitudes,  ascertained  by  experi- 
ment.  Let  us  bear  them  in  mind  whilst  feeling  the  pulse. 

■  "  Manual  of  Physiology,''  2nd  edit.  1887,  p.  255. 


38  HOW  TO  FEEL  THE  PULSE 

Not  only  shall  we  more  correctly  interpret  the  sensa- 
tions conveyed  to  the  finger,  but  we  shall  probably  feel 
more  than  we  otherwise  should  have  felt. 

The  sphygmogram  differs  so  completely  from  the 
wave  itself  that  its  study  is  not  well  fitted  to  assist 
our  notions  of  the  pulse  at  the  present  stage,  although 
invaluable  to  the  advanced  student  once  familiar  with 
the  pulse  as  it  is  felt. 


Intra- arterial  Blood-pressure  ;  and  Peripheral 
Resistance. 

Arteries  during  life  are  always  the  seat  of  interned 
positive  pressure.  Therefore  they  not  only  contain 
blood  at  all  times,  but  an  amount  of  blood  sufficient  to 
oppose  some  resistance  to  the  elasticity  of  the  arterial 
coats. 

The  existence  of  a  permanent  positive  pressure  is 
sufficient  proof  that,  whilst  the  inflow  is  periodically 
renewed,  the  outflow  from  the  arteries  is  controlled  in 
some  permanent  manner.  This  control  or  impediment 
is  known  under  the  name  "peripheral  resistance." 

The  peripheral  resistance  is  made  up  of — 

1.  A  more    or  less  constant  factor — the  friction 

experienced  by  the  blood-stream  in  its  multi- 
tudinous channels;  and 

2.  An    eminently  variable  factor — the  degree  of 

contretction  of  the  capillaries,  and  especially 

of  the  arterioles. 

From  the  latter  cause  variations  will  arise  in  the 
arterial  pressure  as  a  result  of  analogous  variations  in 
the  peripheral  resistance. 


AND  WHAT  TO  FEEL  IN  IT.  3$ 

The  Mean  Arterial  Pressure.- — The  Pulse  curves 
and  the  Respiratory  Undulations  of  Blood-pressure. 

Assuming  for  a  moment  that  the  resistance  is  steady, 
the  recurring  systoles  of  the  heart  will  cause  rhythmic 
variations  of  the  pressure.  These  are  termed  the  (i  pulse- 
curves.19  Inasmuch  as  the  rise  and  the  fall  which  they 
occasion  are  small,  these  oscillations  do  not  greatly 
affect  the  main  level  of  pressure ;  and  we  are  able  to 
speak  of  the  mean  arterial  pressure  as  being  steady. 
The  same  is  true  of  the  rather  larger  oscillations  duo 
to  respiration,  known  as  "  respiratory  undulations?  As 
soon,  however,  as  the  peripheral  resistance  is  altered, 
whether  in  plus  or  in  minus,  the  mean  pressure  suffers 
alteration  also;  and  the  circulation  as  a  whole  requires 
re-adjustment.  This  is  brought  about  in  various  ways, 
but  chiefly  by  a  modification  of  the  strength  of  the 
ventricular  systole,  and  of  its  frequency. 

Amount  of  the  Intraarterial  and  Intra-ventricular 

Pressures. 

Measured  by  the  height  to  which  the  blood  in  the 
artery  can  lift  a  column  of  mercury  placed  in  com- 
munication with  it,  the  blood-pressure  in  the  Brachial 
Artery  (of  man)  is  120  mm.  In  the  warm-blooded 
animals  the  blood-pressure  varies  (according  to  the 
size  of  each)  between  90  mm.  and  upwards  of 
200  mm. 

The  blood -pressure  within  the  human  aorta  has 
been  estimated  at  68  oz.,  or  4  lb.  4  oz.  (in  the  horse 
it  is  11  lb.  9  oz.).  In  the  human  pulmonary  artery, 
if  we  were  to  adopt  as  correct  the  generally  received 
statement  that  the  right  ventricular  wall  is  one-third 
thinner  than  the  left,  it  would  be  about  one-third  less. 
But  according  to    Michael   Foster  (book  i.  chap.   iv. 


4o  HOW  TO  FEEL  THE  PULSE 

p.  253)  the  pressure  within  the  right  ventricle  is 
probably  only  30  to  40  ram.,  whilst  the  left  ventricle 
gives  a  pressure  of  200  mm.  Now,  this  great  difference 
must  presumably  be  proportionate  to  the  difference 
existing  between  the  peripheral  resistance  of  the 
pulmonary  and  that  of  the  systemic  circulations,  and 
therefore  to  the  difference  between  the  intra-pulmonary 
and  the  iutra-aortic  pressures.  The  radial  artery  at 
the  wrist  is  usually  stated  to  have  in  health  a  pressure 
of  4  dr. 

Amount  of  the  Intra- capillary  and  Intravenous 
Blood-pressures. 

The  capillary  Uood-pressun  can  be  roughly  guessed 
at,  rather  than  determined,  with  the  help  of  indirect 
methods.  Thus,  in  the  frog's  web  a  pressure  of 
11  mm.  of  mercury  is  required  to  exclude  the  blood 
from  the  capillaries.  In  the  subungual  capillaries  of 
man  the  pressure  requisite  varies  from  20  to  30  mm. 

In  the  veins,  blood-pressure  is  very  low,  and  becomes 
lower  as  the  heart  is  neared.  In  the  larger  veins 
which  empty  themselves  into  the  thorax  it  is,  during 
the  inspiratory  effort,  negative  or  "  suctional." 


Arterial  Tension. 

The  Artery  as  an  Elastic  and  Contractile  Tube. 

Excessive  internal  pressure  will  shatter  a  rigid 
tube,  whilst  the  same  tube,  if  yielding,  would  be 
dilated  progressively  before  rupture.  In  either  case 
the  internal  pressure  is  disposed  of  in  the  end  owing 
to   the    tube    giving   way.      The   arteries   likewise   ore 


AND  WHAT  TO  FEEL  IX  IT.  41 

ultimately  responsible  for  tfu  maintenance  of  tht   blood- 

They    are    nob    rigid.       Neither    are     they 
merely  elastic  ;   for,  if  so,  they  might  be  well  adapted 
for  a  given  degree  of  pressure,  but  only  imperfectly 
adapted  for  any  other  degree.     Their  elasticity  is  really 
capabU  of  ring  pitch,  thanks  to  the  regulating 

infh  f  thi   muscular  coat.     Moreover,  the  elasticity 

of  an  artery  is,  in  some  proportion,  made  up  of  the 
elasticity  proper  to  its  muscular  fibres ;  and  this  is 
essentially  subject  to  variations.  In  a  word,  arteries 
are  contractile  as  well  as  elastic. 

Varying  Calibre  and  Arterial  Tension. — "Softness  " 
and  "  Hardness  "  of  Pulse. 

So  long  as  the  muscular  fibres  do  not  contract  we 
may  regard  the  artery  as  an  ordinary  elastic  tube 
possessing  a  definite  resistance  and  power  of  recoil. 
Whenever  the  fibres  contract,  whether  much  or  little. 
the  lumen  or  calibre  will  of  course  be  altered  ;  at  the 
same  time,  however,  the  thickness  of  the  arterial 
wall  will  vary,  and  also  its  resistance  and  its 
elasticity. 

Let  us  consider  any  one  of  the  numerous  sizes  of 
which  an  artery  is  capable.  Just  as  an  india-rubber 
air-cushion  may  be  inflated  much  or  little,  and  will 
become,  according  to  the  degree  of  inflation,  tense  and 
hard,  or  soft  and  lax,  so  will  the  arterial  wall  be 
more  or  less  stretched  by  the  blood  within.  As  the 
tension  rises,  its  surface  will  become  more  and  more 
rigid  and  hard,  so  that  little  remains  of  its  natural 
quality  of  softness ;  neither  will  the  mobile  properties 
by  which  we  are  able  to  recognise  the  presence  of  fluid 
be  any  longer  perceived. 

Independently,  therefore,  of  the  size,  the  softness  or 


42  HOW  TO  FEEL  THE  PULSE 

hardness  of  the  arterial  surface  may  become  a  guide  to 
the  degree  of  the  blood -jircssure. 

Influence  of  Elasticity  on  Arterial  Tension. 

The  elasticity  of  the  artery  we  may  compare  to  a 
buffer,  inasmuch  as  it  fulfils  a  double  object — (1)  that 
of  protecting  the  part  subjected  to  pressure,  viz.,  the 
arterial  wall  :  (2)  that  of  storing  up  energy  to  be 
employed  in  propelling  the  blood  as  soon  as  the 
pressure  is  no  longer  in  excess.  In  other  words, 
it  saves  the  artery  from  the  danger  of  rupture  and 
it  assists  the  heart  in  keeping  up  the  general  circu- 
lation. 

From  that  which  has  preceded  it  may  be  gathered 
that,  the  greater  the  systolic  pressure,  so  much  the  more 
energy  will  be  stored  up.  For  a  moment  this  energy 
is  held  in  check  by  the  same  resistance  which  was  the 
means  of  causing  the  pressure  to  rise  ;  and  the  artery 
will  collapse  only  by  degrees  in  proportion  as  the  resist- 
ance becomes  reduced. 

It  is  thus  explained  why,  under  ordinary  circum- 
stances, arterial  tension,  if  it  be  greed,  will  edso  be  sus- 
tained. Conversely,  if  small,  it  will  correspond  to  a 
small  blood-pressure  and  peripheral  resistance  ;  and 
also  to  a  small  store  of  elastic  energy,  which  will 
be  quickly  expended  in  overcoming  the  small  obstacle. 
Thus  low  arterial  tensions  will  not  be  long  sustained. 


DlCROTISM. 


In  some  thin  persons,  if  the  wrist  be  held  up  to  a 
powerful  light,  each  pulse-wave  may  be  seen  to  ex- 
perience during  its  fall  a  momentary  check,  as  though 


AND  WHAT  TO  FEEL  IN  IT.  43 

it  would  swing  up  again  to  its  previous  position.  It  is 
this  secondary  wave  or  beat  which  has  gwen  rise  to  the 
name  Dicrotism.     The  normal  pulse  may  be  dicrotic ;  but 

this  feature  is  not  often  so  sharply  marked  as  to  be 
felt  by  the  finger.  A  keen  eye  will,  however,  detect 
it  in  relaxed  arteries,  the  seat  of  low  tension. 

In  fever,  when  the  arterial  walls  are  relaxed  by 
heat  and  the  blood-tension  is  low,  whilst  the  heart  is 
working  with  short  and  frequent  systoles,  a  careful 
touch  on  the  radial  artery  will  easily  realise  the 
dicrotic  jerk,  which  is  then  much  more  prominent 
than  in  the  normal  state. 

Dicrotism  was  observed  under  these  circumstances 
before  the  days  of  the  sphygmograph.  But  we  owe 
to  the  latter  the  discovery  that  the  dicrotic  event 
occurs  also  in  the  healthy  pulse- wave.  The  student 
will  have  no  difficulty  in  detecting  dicrotism  in  fever ; 
but  only  very  close  attention  will  enable  him  to  trace 
it,  when  present,  in  the  normal  pulse  ;  this  is  an  exer- 
cise the  practice  of  which  cannot  fail  to  educate  his 
touch  in  a  very  high  degree. 

The  Arterial  Foot-jerk  as  a  Type  of  the 
Sphygmograph. 

The  dicrotic  wavelet  is  much  more  readily  detected 
in  the  larger  arteries  than  in  the  radial.  It  is  well 
for  this  reason  to  investigate  the  axillary,  the  brachial, 
the  femoral,  and  the  popliteal  pulses.  The  last  named 
affords  a  very  good  ocular  demonstration  of  the  pulse- 
wave  and  of  its  dicrotism  when  one  leg  is  crossed  over 
the  opposite  knee.  If  the  supported  limb  be  allowed 
to  hang  loosely,  the  foot  may  be  observed  to  oscillate 
with  each  cardiac  systole.  The  jerk  of  the  popliteal 
pulse-wave  is  in  this  case  multiplied  by  the  length  of 


44  HOW  10  FEEL  THE  PULSE. 

the  swinging  limb ;  and  a  writing  lever  suitably  fixed 
to  the  foot  could  be  made  to  yield  a  tracing  of  the 
pulse. 

This  simple  experiment  gives  a  complete  demonstration 
of  the  principle  and  of  the  essential  factors  of  the  sphygmo- 
graph : 

(1)  The  vjeight  of  the  limb  represents  the  pressure 
applied  to  the  artery  ; 

(2)  The  leg  plays  the  part  of  the  lev er ;  and 

(3)  The  action  of  the  spring  is  supplied  by  the  gravi- 
tation of  the  foot  bach  to  its  position  of  rest  after  each 
puke-jerk.  The  dicrotic  or  secondary  jerk  is  in  this 
case  rendered  very  conspicuous. 


CHAPTER   III. 

THE   CHIEF   QUALITIES   AXD  VARIETIES   OF 
THE  NORMAL  PULSE. 


Individual  Variety  Considerable. — Importance  of  a 
Systematic  Study  of  Large  Numbers  of  Pulses. 

There  are  certain  limits  beyond  which  the  exaggera- 
tion of  some  one  feature  of  the  pulse  becomes  an 
abnormality.  But  within  these  boundaries  there  is 
space  for  a  very  large  variety  of  combinations;  so  much 
so  that  it  would  be  difficult  to  meet  with  two  persons 
in  whom  the  radial  pulse  was  exactly  alike.  This 
endless  variety  is  a  source  of  difficulty  in  describing  to 
our  satisfaction  the  pulse  such  as  it  is  felt  in  any 
individual  case.  It  accounts  for  the  large  assortment 
of  adjectives  and  for  the  startling  array  of  figures  of 
speech  which  have  been  called  to  our  aid  (some  of  these 
will  be  found  in  the  Glossary),  and  makes  it  evident 
that  experience  is  the  only  means  to  a  comprehensive 
knowledge  of  the  pulse. 

Let  the  student  note,  however,  that  a  large  expt  rienee 
is  not  necessarily  a  long  one.  Nay,  it  may  be  held  that 
multiple  observations  compressed  within  a  short  space 
of  time  would  probably  lead  to  a  better  and  more 
definite  perception  of  the  varieties  in  type  than  the 
same  number  of  impressions  spread  over  intervals  too 


46  HOW  TO  FEEL  THE  PULSE 

loDg  to  render  comparison  easy.  He  lias  an  opportunity 
that  he  would  do  well  to  utilize  at  an  early  period  of 
his  clinical  studies,  to  systematically  feel  a  consider- 
ablt  number  of  normal  pulses,  and  to  compare  at  first 
such  large  categories  as  the  senile,  the  adult,  and  the 
puerile  pulses;  the  male  and  the  female  pulse  ;  the  pulse 
of  short  and  of  high  stature,  &c.  By  degrees  he  will  rise 
to  a  capacity  for  discerning  finer  distinctions ;  and 
when  his  attention  is  turned  to  the  study  of  disease  he 
will  find  himself  competent  to  observe  and  to  describe 
wherein  any  pulse  may  be  abnormal. 

Systematic  Description  of  the  Qualities 
of  the  Pulse. 

In  these  pages  a  similar  process  is  adopted.  We 
will  proceed  to  analyse  the  pulse,  that  is,  to  consider 
one  by  one  the  physical  qualities  which  make  them- 
selves known  to  us,  and  which  alone  we  are  capable  of 
describing  accurately.  Every  pulse  will  have  to  be 
studied  on  this  basis  at  first, — just  as  an  artist's  first 
sketch  is  built  up  on  anatomical  lines.  Coarse  differ- 
ences between  pulses  will  be  brought  to  light  by  the 
method,  but  the  finer  touches  which  will  make  the 
description  so  like  the  original  as  to  convey  a  complete 
mental  picture  of  it  can  hardly  be  expected  at  an  early 
stage  of  study. 

Large  and  Small  Size  or  Volume  of  Pulse. 

A  "  large  pulse  "  and  a  "  small  pulse  "  are  expressions 
which  appeal  to  any  person  who  has  compared  with 
each  other  a  few  examples  of  the  healthy  pulse.  All 
beginners  are  exposed  to  the  risk  of  getting  an  in- 
adequate idea  of  the  size  of  the  radial  pulse  from  not 


AM)  WHAT  TO  FEEL  IN  IT.  47 

having  sufficiently  relaxed  the  tendons  with  which  it  is 
surrounded.  If  this  be  done,  that  which  appeared  pre- 
viously to  be  a  small  pulse  may  be  ultimately  recog- 
nised as  a  relatively  large  one. 

T/(<  largest  "  volume"  of  pulse  results  from  a  com- 
bination of  two  factors : 

1.  A  strong  heart-beat,  and 

2.  A  yielding  arterial  wall,  alike  capable  of  col- 

laps*  and  of  distension. 

Conversely,  <<  small  pulse  would  be  found  in  those 
whose  arteries  were  not  so  yielding,  or  the  heart  so 
strong. 

It  must  be  noted,  however,  that  an  artery  may  be 
large  and  yet  very  unyielding  when  the  superior  power 
of  the  heart  has  gradually  brought  about  general 
arterial  dilatation. 

As  a  broad  statement;  it  is  true  to  say  that  a  "  large 
pulse"  is  generally  infrequent;  a  small  pulse,  frequent. 

So-called  "  Fulness  "  and  "  Emptiness  "  of 
Pulse. 

"  Fulness''  and  "  emptiness,"  when  applied  to  the 
pulse,  are  expressions  almost  entirely  metaphorical. 
Arteries  are  never  empty  daring  life,  although  they  may 
contain  much  less  blood  at  one  time  than  at  another. 
In  truth,  arteries  adopt  their  size  to  their  contents,  and 
in  that  sense  they  are  always  full.  Any  tendency 
to  a  vacuum,  if  it  existed,  would  produce  a  collapse  of 
their  walls ;  and  at  the  same  time  would  act  as  a 
negative  or  suctional  force,  detaining  the  blood  within 
them. 

By  "full  pulse"  is  presumably  meant  a  stout  and 
firm  pulse,  not  readily  subsiding ;  by  "  empty  pulse," 
one  quickly  vanishing  after  a  spasmodic  beat.     Here 


4S  HOW  TO  FEEL  THE  PULSE 

again  we  should  gain  in  clearness  by  avoiding  the 
words  "  full"  and  "  empty  "  and  using  the  equivalents 
which  more  truly  correspond  to  the  things  as  they 
are. 

"Strength."  and  "Weakness"  of  Pulse-wave. 

It  is  much  less  clear  what  meaning  should  be 
attached  to  the  terms  "strong"  and  "weak*'  pulse. 
Nothing  is  more  probable  in  appearance  than  that  a 
considerable  rise  and  expansion  of  the  artery  should 
mean  a  powerful  cardiac  systole,  and  therefore  a  strong 
pulse.  Often  enough  this  is  the  case.  Very  frequently, 
hoivevcr,  the  size  of  the  pulse  is  not  ei  reliable  meeisure  of 
its  strength.  The  large  and  full  pulsation  is  apt  to  be 
very  short  and  one  easily  compressed.  Resistance,  on 
the  other  hand,  is  often  a  character  of  pulses  whose 
beats  are  not  tall,  and  which  possess  but  moderate 
volume.  We  shall  therefore  connect  the  expression 
strong  and  weak  rather  with  the  lifting  power  of  the 
pulse-wave  than  with  the  degree  of  expansion  or  height 
of  rise  special  to  the  individual  beats  when  no  external 
pressure  is  superadded. 

The  paradox  apparently  implied  in  the  association  of 
contradictory  terms,  such  as  u  large  pulse  of  small 
strength,"  will  be  partly  explained  away  by  later 
remarks  on  arterial  tension,  but  it  may  even  at  this 
stage  be  pointed  out  that  the  smaller  size  which  a 
pulsation  may  possess  sometimes  coincides  with  very 
powerful  cardiac  effort,  and  with  considerable  strength, 
just  as  a  spiral  spring  partly  weighted  down  by  a 
heavy  load,  nevertheless  gives  us  proof  of  greater  power 
than  we  can  be  sure  of  in  the  taller  spring  which 
no  weight  has  yet  tried. 

Let  us  be  very  careful,  therefore,  in  every   case   of 


AND  WHAT  TO  FEEL  IN  IT.  49 

large  pulsation  to  try  the  effect  of  a  strong  pressure  of 
the  finger,  and  to  notice  the  relative  duration  of  the 
pulse-wave,  and  the  condition  of  the  artery  in  the 
intervals  between  successive  waves. 

The  Artery  during  the  Interval  between 

Beats. 

Hitherto  we  have  referred  only  to  the  strength  of 
the  pulsation.  Shifting  now  the  ground  of  our  ob- 
servation from  the  pulsation  to  the  condition  of  the 
artery  between  Successive  beats  we  shall  find  that,  among 
the  large  pulses,  some  persist  during  the  interval 
whilst  others  fade  away  after  the  systolic  jerk.*  The 
first  set  are  strong  as  well  as  large  pulses;  the  second, 
weak  in  spite  of  their  large  siz>:.  Conversely,  a  small 
pulse  may  become  imperceptible  between  the  beats  ; 
it  is  then  weak  as  well  as  small.  But  it  may  be  strong 
although  small,  if  during  the  intervals  it  resist  the 
ordinary  attempts  at  compression. 

Softness  and  Hardness  of  Pulse. 

"  Softness  "  and  ';  hardness  "  are  qualities  of  which 
the  touch  is  an  accurate  judge :  the  words  in  this 
case  are  truly  descriptive.  A  pulse  may  he  hard  from 
undue  pressure  of  its  fluid  contents,  or  from  undue  solidifi- 
cation, of  the  arterial  ivalls.  It  is  not  always  easy 
to  tell  whether  the  hardness  is  due  to  blood-pressure 
or  to  tissue  condensation  of  the  arterial  surface. 
Both  these  variations  occur  as  a  senile  change.  A 
soft  pulse  is  produced  when  the  arterial  walls  are  free 

*  These  remarks  apply  to  pulses  in  general,  not  to  the  pathological 
variety  known  as  Corrigan's  pulse,  in  which  the  beat  is  forcible,  but 
ends  abruptly. 

n 


50  HOW  TO  FEEL  THE  PULSE 

from  thickening,  and  the  blood  is  free  from  undue 
pressure.  Softness  and  elasticity  (during  the  periods 
of  bodily  and  mental  rest)  are  attributes  of  a  juvenile 
pulse. 

Elasticity  of  Pulse. 

Arteries  in  health  are  both  yielding  and  very  elastic. 
Age  sooner  or  later  impairs  the  natural  elasticity  and 
expansibility  of  the  vessels.  The  same  regressive 
change  may  also  result  from  disease,  independently  of 
age. 

The  presence  of  the  elastic  property  is  easily  recog- 
nised in  the  recoil  of  the  artery  after  each  pulsation. 
Its  absence,  "where  this  recoil  does  not  take  place,  is 
more  difficult  to  prove ;  the  systolic  pressure  in  some 
individuals,  and  at  some  times,  is  so  great  and  so  long 
sustained  that  the  elastic  force  of  the  artery  is  over- 
powered. Elasticity  is  then  not  necessarily  extinct ; 
it  may  be  simply  latent  because  maintained  on  the 
stretch.  The  strain  which  this  implies  is  considerable, 
and  it  could  not  be  kept  up  for  protracted  periods 
without  lasting  impairment  and  ultimate  destruction 
of  the  elastic  property. 

Swiftness  and  Slowness  of  Pulse ;   or  Short  and 
Long  Duration  of  the  Pulse-wave. 

A  swift  pulse  is  one  rapidly  passing  from  the  period 
of  arterial  expansion  to  that  of  collapse.  This  certainly 
means  that  tlie  wave  travels  fast  ;  it  may,  in  addition, 
mean  that  its  length  is  reduced.  Rapidity  of  the  pulse- 
wave  is  usually  associated  with  frequency  of  rate. 
The  reverse  is  the  case  with  the  slow  pulsation,  which 
is  commonly  an  infrequent  one.  Swiftness  is  almost 
invariably,    no    less    than    frequency,     the     result    of 


AND  WHAT  TO  FEEL  IN  IT.  51 

diminished  peripheral  resistance;  and,  conversely,  slow- 
ness and  infrequency  indicate  an  abnormal  obstacle, 
occurring  somewhere  in  the  arterial  or  in  the  capillary 
circulation.  Contraction  of  the  arterioles  constitutes  an 
obstacle  of  this  kind.  A  well-known  instance  is  the 
contraction  of  the  cutaneous  vessels  as  a  result  of  cold. 
Rigidity  of  the  arteries,  as  in  senile  thickening  of  their 
coats,  is  another  form  of  increased  resistance,  more  seri- 
ous than  the  first,  because  permanent  and  progressive. 

Frequency  and  Infrequency  cf  Pulse ;    or 
Pulse-rate. 

Xo  uncertainty  can  possibly  attach  to  the  use  of 
these  expressions.  They  correspond  to  the  old  Latin 
terms  pulsus  creber,  pulsus  rarus.  They  are  much  to 
be  preferred  to  the  words  a  rapid"  and  "slow,"  which 
are  applicable  to  the  rate  of  progress  of  the  pulse-wave 
as  well  as  to  the  rate  at  which  the  cardiac  beats 
succeed  each  other.  Nevertheless,  the  expressions 
"  quick,"  "  fast,"  or  "  rapid  pulse  " — and  ;*  slow  pulse  " 
have  passed  into  currency,  and  are  generally  under- 
stood to  apply  to  the  pulse-rate.  It  is  worth  while, 
however,  to  be  absolutely  correct  in  this  matter  for  the 
sake  of  complete  clearness,  and  to  speak,  not  of  the 
:;y/?//s'',"  but  of  the  "pulse-rate,"  as  being  either  slow  or 
fast. 

Accelerating  and  Retarding  Influences. 

The  causes  which  accelerate  the  pulse-rate  are 
many,  and  a  majority  of  them  are  physiological. 
Among  the  latter  may  be  specially  mentioned  physical 

rti'iiiy  psychical  excitement,  and  external  heat. 

Pathologically,  an  increase  in  the  pulse-rate  is  bound 


52  HOW  TO  FEEL  THE  PULSE 

up  with  a  rise  in  the  internal,  or  body-temperature,  in 
fever.  Apart  from  fever,  it  is  often  witnessed  as  a 
result  of  disordered  nerve-function,  and  as  a  mechanical 
consequence  of  various  forms  of  heart  disease. 

On  the  contrary,  infrequency  of  pulse  is  more  often 
due  to  pathological  than  to  physiological  causes.  It  is 
true  that  during  rest,  and  especially  in  healthy  sleep, 
the  heart  slackens  speed.  Again,  with  some  indivi- 
duals, a  remarkable  slowness  of  the  heart-rate  is 
"natural"  or  "constitutional."  Of  this  the  most 
famous  historical  instance  is  that  of  the  great 
Napoleon,  whose  pulse-rate  is  stated  to  have  been 
habitually  40.  More  commonly,  however,  infrequency 
is  the  result  of  some  definite  abnormality,  whether 
cardiac  or  vascular.  A  very  slow  pulse-rate  is  often 
witnessed  in.  fatty  degeneration  of  the  heart,  but  slowness 
is  by  no  means  invariably  present  in  this  disease. 
Sometimes  an  abnormally  slow  pulse-rate  is  the  result 
of  excessive  feebleness  of  some  of  the  heart-lints,  whereby 
they  are  unable  to  reach  the  peripheiy  (see  Abortive 
Beats  and  Linked  Beats). 

Putting  aside  the  exceptional  cases  just  mentioned, 
a  determination  of  the  pulse-rate  is  so  easy  of  per- 
formance that  this  subject  has  been  very  thoroughly 
investigated.  The  following  are  the  results,  some  of 
which  are  familiar  to  every  student  of  physiology : — 

I.  The  Normal  Rate  in  the  Two  Sexes. 

The  normal  frequency  per  minute  is — 

72  in  the  adult  male, 
80  in  the  adult  female  ; 

(according  to  Ozanam,  respectively  60  and  70). 


AND  WHAT  TO  FEEL  IN  IT. 


53 


II.  Influence  of  Age. 

The  pulse-rate  varies  with  age  in  the  following 
manner : — 

Pulse-rate  in  the  foetus       .....  14(1-150 

,,        .,  at  birth 130-140 

„  at  1  year  of  age         ....  120-130 

„        ,,  at  2  years  of  age        ....  105 

„  at  3       „„•;.:.  100 

„        »  at  4       ,,         „            .         .         .         .  <J7 

„        „  at  5      „        „            ....  94-90 

„        ,,  at  10     ,,         ,,             .         .          about  90 

.,        ,,  from  10  to  15  years  of  age         .         .  78 

,,         ,,  from  15  to  50       ,,         ,,              .  70 

,,        „  at  60  years  of  age     ....  74 

,,         ,,  at  80       ,,         ,,           ....  79 

„        „  from  80  to  90   .          .         upwards  of  80 

According  to  the  above  figures,  which  are  taken  from 
Stirling's  translation  of  Landois'  Physiology,  it  will  be 
seen  that,  in  the  adult,  any  pulse-rate  between  the  rates 
of  60  and  80 ^pulsations  per  minute  /night  be  regarded  as 
a  normal  rate*,  any  rate  below  60  might  be  regarded  as  a 
slow  rate,  any  rate  above  90  //right  be  regarded  as  a  quick 
rede. 

III.  The  Influence  of  Stature. 

The  influence  of  body-length  is  to  lessen  the  frequency 
of  pulse  and  to  increase  the  blood-pressure. 

Czarnecki  derived  the  following  results  with  the  help 
of  the  formulae  of  Volkmann  and  Rameaux :  * 

Height. 
80-90  cm. 
90-100 
100-110 
110-120 
120-130 
130-140 


Rate.       < 

Calculated. 

.      103      .. 

90 

91      .. 

86 

87      .. 

81 

.        84     .. 

78 

.       78     .. 

75 

.       76     .. 

72 

Height. 

R^te. 

Calculated 

140-150  cm. 

.     74 

...     69 

150-160 

.     68 

...     67 

160-170 

.     65 

...     65 

170-180 

.     64 

...     63 

above  180 

.     60 

...     00 

*  See  Landois'  Physiology,  translated  by  Stirling,  1885,  p.  142. 


54  HOW  TO  FEEL  THE  PULSE 

IV.  The  Influence  of  the  Hour  of  Day. 

The  following  figures  are  given  by  Landois  in  con- 
nection with  variations  in  frequency  : 

.5-6  A.M. Gl  pulsations. 

8-1U  A.M 74  „ 

1H-2  P.M a  fall. 

3  p.m.  (dinner-time)  and  till  G  or  8  P.M.  a  rise  to  70  ,, 

--12  p.m a  fall  to  54  „ 

Thus  the  maximum  is  in  tlw  forenoon,  the  minimum 
at  midnight. 

V.  The  Influence  of  Sleep  and  the  Waking  State. 

The  preceding  table  shows  that  sleep  is  accompanied 
by  a  slow  rate  of  heart-beat  and  that  the  quickest  rate 
belongs  to  the  hours  of  complete  wakefulness  and 
activity.  Moreover,  the  act  of  awaking  is  associated 
with  a  rise  in  the  pulse-rate,  the  more  marked  if  the 
awakening  be  abrupt  and  not  spontaneous. 

VI.  The  Influence  of  Meals  and  of  the  Fasting 

State. 
The  pulse  is  kept  low  as  well  as  slow,  by  fasting. 
It  is  accelerated,  and  at  the  same  time  excited,  by  meals 
(febris  a  2"'"  ndio). 

VII.  The  Influence  of  the  Quantity  and  of  the 

Quality  of  Food. 

The  acceleration  brought  about  by  a  large  meal  is 
greater  than  that  due  to  a  small  one,  and  it  is  main- 
tained for  two  or  three  hours.  But  the  variety  and 
especially  the  temperature  of  the  food  have  very 
distinct  effects  on  the  pulse,  irrespective  of  quantity. 
Warm  foods,  and  especially  warm  drinks,  immediately 


AND  WHAT  TO  FEEL  IN  IT.  55 

raise  the  pulse-rate ;  cold  food  or  drinks  only  after  a 
while  (Ozanam).  Vinegar,  sour  milk,  fruit  are  said  to 
depress  the  pulse-rate.  The  acceleration  due  to  nitro- 
genous foods  is  less  delayed,  but  that  due  to  non-nitro- 
genous foods  lasts  longer. 

Alcohol,  Tea,  and  Coffee. 

The  accelerating  action  of  these  beverages  is  too 
familiar  to  call  for  comment.  In  the  case  of  tea  or 
coffee  it  is  said  to  disappear  within  an  hour,  but,  as  is 
well  known,  individual  susceptibility  varies  greatly. 

VIII.  The  Influence  of  Tobacco-smoking. 

According  to  Nick  (quoted  by  Ozanam),  acceleration 
is  produced  even  in  those  who  have  acquired  the  habit. 
The  increase  of  pulse-rate  occasioned  by  smoking  a  pipe 
of  tobacco  in  the  morning  "  may  amount  to  from  15 
to  20  pulsations,  and  last  an  hour." 

IX.  The  Influence  of  Muscular  Exercise  and  of  Eest. 

Best  slews  the  pulse;  muscular  exercise  invariably 
quickens  it;  roughly  speaking,  in  proportion  to  the 
amount  of  the  exertion.  This  subject  was  carefully 
studied  by  Nick  (1831).  His  interesting  results  are 
in  harmony  with  modern  physiological  data. 

X.  The  Influence  of  Posture. 

What  has  just  been  said  almost  implies  that  attitudes 
will  influence  the  rapidity  of  the  pulse  in  proportion  to 
the  muscular  effort  which  they  necessitate.  This  was 
proved  to  be  the  case  by  Guy.  Standing  up,  being  much 
more  laborious  than  sitting  up,  accelerates  the  pulse  in  a 


56  HOW  TO  FEEL  THE  PULSE 

greater  measure  than  the  latter;  and  it  may  be  due  to 
the  fact  that  there  is  more  energy  in  the  usual  attitude 
of  a  man  than  in  that  of  a  woman  that  this  acceleration 
is  less  in  the  latter  than  in  the  former. 

XI.  The  Influence  of  Emotion,  of  Psychical  and 

of  Mental  Excitement. 

The  usual  effect  is  em  acceleration  ;  but  in  some  cases 
emotion,  especially  if  it  be  of  the  nature  of  a  severe 
shock  to  the  feelings,  produces  slowing  and  at  the  same 
time  temporary  feebleness  of  the  heart's  beat  (faintness 
and  fainting). 

The  influence  of  the  psychical  and  sensorial  factors 
is  shown  in  the  increase  in  pulse-rate  and  blood-pressure 
induced  in  animals  as  well  as  in  man  by  music. 

XII.  The  Influence  of  Variations  in  Barometric 

Pressure. 

Although  slight  oscillations  in  the  atmospheric 
pressure  do  not  perceptibly  alter  the  pulse-rate,  this 
influence  is  very  marked  when  the  changes  in  pressure 
are  considerable.  Thus,  at  high  altitudes,  the  pulse 
beats  at  a  much  increased  rate ;  and,  conversely,  at  low 
levels,  such  as  that  of  the  Dead  Sea  (430  metres  below 
the  sea-level)  or  in  deep  mines,  the  rhythm  of  the  heart 
is  much  slowed  (Ozanam). 

XIII.  The  Influence  of  Variations  in  the  External 

Temperature. 

Heat  accelerates  the  heart's  action ;  cold  diminishes  the 
rate.  It  is  owing  to  this  agency  that  inhabitants  of  a 
cold  climate  have  a  slower  pulse  than  the  inhabitants 
of  tropical  regions  (Ozanam).     A  practical  demonstra- 


AND  WHAT  TO  FEEL  IN  IT.  57 

tion  of  this  effect  of  external  heat  is  readily  obtained 
in  the  hot-room  of  a  Turkish  bath. 

XIV.  The  Influence  of  Variations  in  the 
Temperature  of  the  Body. 

Whenever  the  body  heat  sinks  below  the  normal, 
the  rapidity  of  the  heart's  action  (cceteris  paribus)  is 
diminished.  On  the  contrary,  a  rise  above  the  normal 
temperature  is  accompanied  by  acceleration.  The 
quick  pulse-rate  in  fever  is  in  great  part  due  to  this 
cause,  and  the  acceleration  is  proportionate  to  the  rise. 
According  to  Sir  William  Aitken,  a  rise  of  one  degree 
Fahrenheit  corresponds  very  closely  to  an  increase  of 
10  pulsations  per  minute. 


CHAPTER   IV. 
THE  CHIEF  ABNOKMALITIES  OF  THE  PULSE. 


In  this  chapter  are  briefly  considered : 

I.  The  variations  in  size. 

II.  The  variations  in  rhythm. 

III.  The  incompressible  pulse  ;  and 

IV.  The  recurrent  pulse. 

On  the  Use  of  the  Terms  "  Irregularity  "  and 
"  Unevenness.', 

Regularity  in  the  intervals,  and  equality  in  the  beats, 
are  essential  features  of  the  normal  pulse.  In  disturbed 
function  either  one  or  the  other  or  even  both  may  be 
affected.  Since  alterations  of  this  kind  are  of  common 
occurrence,  clearness  would  best  be  served  by  the  use 
of  two  distinct  terms.  Although  irregularity  may  be 
understood  to  apply  both  to  disturbances  in  time  and 
to  variations  in  strength;  yet  unevenness  is  specially 
suggestive  of  alterations  in  level,  and  most  fitly  ex- 
presses the  broken  line  formed  by  the  summits  of 
unequal  pulse-waves.  Without  unfair  restriction  and 
with  great  advantage  we  may  therefore  reserve  the 
terms  "  uneven  pulse  "  for  the  condition  of  unequal  pulse 
heats,  and  "  irregular  pulse"  for  disturbance  of  rhythm, 
or  arhythmia.  The  strength  of  pulsations,  as  well  as 
their  frequency,  are  subject  to  fluctuations  according 


HOW  TO  FEEL  THE  PULSE.  59 

to  the  time  of  day  and  to  its  events ;  it  is  necessary, 
therefore,  to  state  that  "irregularity"  and  "  uneven- 
ness  "  would  be  applicable  only  to  changes  more  rapid 
than  these. 

I. 

The  Variations  m  Size. 
"  Unevenness  "  of  Pulse. 

In  health  the  size  of  the  pulse  is  subject  only  to  the 
physiological  variations  previously  described.  It  main- 
tains a  uniform  level  so  long  as  no  changes  occur  in 
the  external  circumstances.  In  some  persons,  however 
healthy  according  to  appearances  and  as  regards  their 
own  feelings,  the  heart  acts  unevenly;  in  them  the 
unevenness  is  almost  always  associated  with  irregularity 
of  pulse.  Although  the  general  strength  need  not 
suffer,  we  recognise  in  this  symptom  evidence  of  dis- 
ordered function.  Cases  of  this  kind  strikingly  illustrate 
the  meaning  of  functional  as  contrasted  with  organic 
disease.  In  the  latter,  unevenness  arises  as  a  result  of 
anatomical  changes  in  the  heart  or  its  valves,  and  has 
a  widely  different  significance.  The  unevenness  and 
irregularity  special  to  the  purely  nervous  affections  are 
often  alarming  to  the  patient  when  first  discovered  by 
him ;  and  even  to  the  observer  accustomed  to  meet 
with  them,  there  is  always  something  strange  in  the 
sensation  which  they  convey  ;  for  rhythm  and  evenness 
are  natural  to  organic  life  and  their  absence  is  dis- 
quieting even  when  it  is  not  dangerous. 

Unevenness  in  pulse  has  two  distinct  types  : 

(1)  The  unevenness  may  he  periodic ^  and  in  this  sense 
regular  ;  or 

(2)  it  may  follow  no  definite  rule. 


6o  HOW  TO  FEEL  THE  FULSE 

Periodic  Unevenness. 

Of  this  we  sometimes  meet  with  striking  examples. 
Pulsus  alternaus  is  characterised  by  unevenness  in  the 
size  of  every  other  beat.  It  is  a  good  instance  of  the 
unusual  combination  of  regularity  in  rhythm,  with  un- 
evenness in  size.  The  relative  value  of  the  two  beats 
in  'pulsus  alternans  varies  in  different  cases.  The 
smaller  beat,  should  it  be  very  small,  may  be  "  abor- 
tive," i.e.,  may  not  reach  the  wrist  with  sufficient 
force  to  be  felt.  The  radial  pulse  will  be  regular  but 
its  rate  will  then  be  half  the  rate  of  the  cardiac 
pulsation. 

In  pulsus  bigeminus  the  beats  run  in  pairs,  between 
which  a  relatively  long  interval  occurs. 

Pulsus  trigeminus,  even  less  common  than  the  pre- 
ceding form,  resembles  it  in  the  long  intervals  which 
separate  groups  of  pulsations.  Each  group  in  this 
case  consists  of  three  beats. 

Abortive  Beats. 

An  instance  of  single  abortive  beats  has  been  given 
in  connection  with  pulsus  alternans.  Two  or  even 
three  abortive  beats  may  succeed  one  strong  beat. 
This  occurs  in  a  good  percentage  of  the  cases  of  very 
slow  pulse.  Commonly  the  accessory  beats  are  so  small 
that  even  the  stethoscope  may  fail  to  render  them 
plainly  audible,  and  they  may  be  but  feebly  indicated 
in  the  sphygmographic  pulse-tracing. 

Non-Periodic  Unevenness. 

Often  abortive  beats  are  isolated  and  occur  at 
irregular  intervals.  In  this  case  the  finger  resting  on 
the  pulse  would  notice  a  sudden  blank  followed  by  a 
return  to  the  normal  rhythm.     But  if  the  heart  's  action 


AND  WHAT  TO  FEEL  IN  IT.  61 

had  meanwhile  been  under  observation  with  the  binaural 
stethoscope,  two  events  would  have  been  noticed : 
(1)  an  unusually  early,  unusually  short  and  spasmodic 
beat,  seeming  to  overtake  the  preceding  beat  (just  as 
in  tripping  or  stumbling,  one  foot  is  hurriedly  brought 
forward  to  save  a  fall)  ;  (2)  an  unusually  long  pause. 
This,  taken  together  with  the  short  beat,  is  nearly 
equivalent  to  the  added  durations  of  one  ordinary  beat 
and  two  ordinary  pauses. 

Linked  Beats. 

Instead  of  one  there  may  be  two  abortive  beats 
rapidly  succeeding  one  another,  and  followed  by  a  long 
pause.  Both  in  this  case  and  in  the  preceding  one 
the  group  formed  by  the  large  beat  and  the  small 
beats  receives  the  name  of  linked  pulsations. 

Difference  between  Linked  Beats  and  Pulsus 
Bigeminus  and  Trigeminus. 

It  often  occurs  that  the  linked  beats  are  felt  at  the 
wrist,  as  well  as  heard  at  the  heart.  The  student  will 
have  no  difficulty  in  knowing  them  and  putting  upon 
them  the  correct  name  if  he  will  bear  in  mind  that, 
in  the  other  variety  (the  pulsus  bigeminus  and  trigeminus 
of  Traube),  the  size  of  the  beats  in  each  group  is 
nearly,  if  not  quite  equal ;  they  are  complete  beats.  In 
linked  heeds  this  is  not  the  case ;  the  second  beat 
occurs  before  the  natural  end  of  the  previous  one  ; 
and  whilst  curtailing  this,  it  is  itself  much  hurried  and 
very  imperfect. 

The  term  stumbling  or  tripping  pulsation  describes 
the  irregular  and  spasmodic  heart's  action  which  causes 
the  linked  beats.  It  is  applicable  to  the  pulse  as  well 
as  to  the  heart's  action. 


62  HOW  TO  FEEL  THE  PULSE 

Combined  Unevenness  and  Irregularity. 

Absolute  unevenness,  associated  with  absolute  irre- 
gularity, is  a  common  form  of  functional  disturbance. 
Among  the  valvular  affections  it  is  distinctive,  although 
not  exclusively  so,  of  mitral  regurgitation,  particularly 
in  its  worst  form  and  in  its  later  stages.  Instances  of 
this  combination  have  been  alluded  to  under  the  head 
of  abortive  and  linked  beats. 


II. 

The  Variations  in  Rhythm. 

"  Irregularity  "  of  Pulse.     Intermittence. 
Allorhythmia  and  Arhythmia. 

The  remarks  made  in  connection  with  unevenness 
of  the  pulse  give  prominence  to  the  fact  that  an 
uneven  pulse  is  most  commonly  irregular  also.  Even 
in  those  instances  where  periodicity  is  traceable  in  the 
recurrence  of  unequal  beats,  the  rhythm  is  altered 
{allorhythmia)  though  it  is  not  quite  destroyed.  Indeed, 
if  the  heart's  action  alone  were  under  consideration,  it 
might  be  truly  said  that  marked  unevenness  is  always 
coupled  with  irregularity,  and  vice  versa. 

In  the  radial  pulse,  however,  the  cardiac  events  are 
not  always  faithfully  represented.  Slightly  uneven 
systoles  are  in  a  measure  equalised  by  the  elasticity  of 
the  intervening  arteries.  On  the  other  hand,  very 
feeble  systoles  are  often  not  conveyed  as  pulse-beats  as 
far  as  the  wrist.  It  will  often  happen,  therefore,  that 
the  radial  pulse  will  be  very  irregular  in  rhythm 
without  any  proportionate  unevenness  in  its  beats. 
Thus   we  may,  without  doing  any   violence   to    facts, 


AND  WHAT  TO  FEEL  IX   II.  63 

award  a  separate  consideration  to  the  subject  of  irre- 
gularity. 

Intermittence  and  Allorhythmia. 

Tie  re  an  two  types  of  irregularity : 

1.  The  pulsi  rhythm  may  b\  suddenly  interrupted  by 

a  pause  of  greater  duration  than  normal.  The  pulse 
i<  then  said  to  be  intermittent.  This  is  the  common 
form. 

2.  The  pulse,  whilst  not  suffering  any  stoppage, 
may  suddenly  undergo  acceleration  or  slowing,  It  is 
then  said  to  be  allorhythmic. 

Both  these  forms  of  irregularity  may  be  periodic 
or  non-periodic,  and  we  shall  have  four  varieties  to 
consider. 

1.  Thi  periodic  or  regular  intermittence* 

2.  TIi'  irregular  intermitted     . 

3 .  TIi  t  per  u » lie  or  regular  a  Uo  i  -It  yth  mia. 

-1-.    The  non-periodic  or  irregular  allorhythmia. 

We  may  at  once  dismiss  the  last  two  varieties  as 
not  possessing  at  the  present  stage  any  practical 
interest,  and  confine  our  attention  to  the  intermittent 
pulse. 

Intermittence  at  the  Wrist. 

As  previously  hinted,  the  dropping  of  a  beat  at  the 
wrist  may  mean  very  different  cardiac  events.  This 
is  clearly  shown  by  what  has  been  said  under  the 
heading  "  Abortive  Beats.'" 

One  of  three  things  may  have  happened  : 

1.  The  missing  bo't  may  never  ham  been  given  hy  the 
heart.     (Intermittence  at  the  heart.) 

2.  It  may  have  bet  n  a  feeble  heart-heat,  of  the  nature 
of  the  weaker  beat  in  pulsus  alternans,  and  too  feeble 
to  be  felt  at  the  wrist 


64  HOW  TO  FEEL  THE  PULSE 

3.  It  may  have  been   of  the  /'."fur-   of.  <<   Ivnl 

(hurried  and   incomplete,  and   too  early  as  well  as  too 
short). 

The  first  of  these  conditions,  namely — ca  vter- 

mitti  nee — is  the  most  common,  as  a  cause  for  intermit  - 
tence  at  the  wrist. 

The  Varieties  of  Rhythm  in  Intermittence. 

Although  it  is  important  to  hold  fast  by  the  distinc- 
tion between  the  regular  and  the  irregular  intermissions, 
we  are  not  at  present  in  possession  of  definite  knowledge 
as  to  the  relative  value  of  the  two  classes  of  events  as 
regards  either  diagnosis  or  prognosis.  The  degree  of 
the  abnormality  would  seem  to  be  more  important  than 
the  kind ;  and  yet  in  some  cases  the  irregularity  may 
be  considerable  without  any  apparent  detriment  to 
health  or  capacity  for  work.  (The  most  common  asso- 
ciation and  the  most  probable  cause  of  this  peculiarity 
is  dyspepsia  in  some  form  or  other  :  such,  at  least,  is 
the  current  opinion.)  Nevertheless,  in  the  clinical 
study  of  cases  it  is  most  desirable  to  discover  and  note 
any  periodicity  which  may  exist,  or  to  ascertain  that. 
on  the  contrary,  the  intermittence  is  subject  to  no 
definite  rhythm. 

Absolute  Arhythmia. 

Outside  the  large  group  of  functional  (usually  dys- 
peptic) cases  to  which  reference  has  been  made. 
complete  arhythmia  (absolute  irregularity)  is  met  with  in 
eases  of  cardiac  exhaustion,  and  during  the  agony  of 
death  by  gradual  heart  failure.  This  fact  contains 
the  suggestion,  which  was  successfully  put  to  the  test 


AND  WHAT  TO  FEEL  IX   IT.  65 

by  Knoll.*  that  irregularities  such  as  pulsus  trigeminus 

and  trigeminus^  and  arliytkmia  in  general,  might  be 
induced  by  casting  upon  the  heart  an  amount  of  work 
disproportionate  to  its  energy.  Complete  arhythmia  is 
always  coupled  with  a  high  degree  of  unevenness  of 
beat. 

Classical  Varieties  of  Uneven  and  Irregular 
Pulse,  known  under  Special  Names. 

Under  this  heading  we  shall  proceed  to  a  short 
account  of  the  following  varieties  : — 

1.  Pulsus  ineiduus, 

2.  Pulsus  myurus, 

3.  Pulsus  paradoxus. 

The  old  names,  pulsus  ineiduus,  pulsus  myurus,  both 
apply  to  unevenness  of  pulse.  Pulsus  paradoxus  is  both 
uneven  and  irregular. 

Pulsus  ineiduus,  or  waxing  and.  waning  pulse,  con- 
sists of  successive  short  periods  of  pulsations,  beginning 
with  a  strong  beat.  and.  after  gradual  diminution, 
ending  with  a  weak  beat. 

In  pulsus  myurus — a  pathological  curiosity — the 
pulse  strength  gradually  tapers  away  u  like  the  tail  of 
a  rat."  In  former  days  the  practice  of  bleeding  ad 
aniuxa:  dereliquium  usque  afforded  frequent  opportunities 
for  feeling  this  form  of  pulse.  It  may  also  be  observed 
in  the  umbilical  artery  at  birth  whilst  the  placental 
circulation  is  being  diverted. 

Pulsus  Paradoxus,  cum  Inspiratione  Intermittens. 

llis  pulsus  paradoxus  may  be  regarded  as  a  special 
variety  of  pulsus  ineiduus,  in  which — 

*  See  Landois'  Physiology,  translated  by  Stirling,  edition  1SS5, 
p.  143. 

E 


66  HOW  TO  FEEL  THE  PULSE 

(a)  The  unevenness  coincides  with,  and  is  depen- 
dent upon,  the  movements  of  respiration,  and 

(b)  The  beats  may  be  so  much  reduced  as  to  cease 
to  be  felt  at  the  wrists. 

The  cardiac  rhythm  and  blood-pressure  are  normally 
influenced  by  respiration,  the  rate  decreasing  slightly 
and  the  pressure  increasing  during  inspiration,  whilst 
the  reverse  takes  place  during  expiration.*  The  variety 
described  as  paradoxical  by  Kussmaul,  presents,  on  the 
contrary,  an  inspiratory  fall  of  pressure  in  the  peri- 
pheral arteries. 

Normally,  the  inspiratory  negative  pressure  within 
the  thorax  takes  effect  upon  the  subclavian  arteries, 
and,  according  to  Marey,  upon  the  aorta  itself.  This 
would  tend  to  lower,  during  inspiration,  the  pressure 
within  the  arteries  of  the  upper  limb.  But,  in  opposi- 
tion to  this  result,  a  stronger  influence  prevails  under 
ordinary  circumstances — namely,  that  of  the  increased 
in-tdke  of  venous  blood  by  the  heart  daring  early  inspira- 
tion. It  is  clear,  however,  that  any  cause  which  would 
intensify  thoracic  aspiration  beyond  a  certain  point, 
must  lead  to  an  inspiratory  fall  of  pressure.  The 
strong  efforts  of  dyspnoea  in  cases  where  the  lungs, 
owing  to  the  presence  of  fluid  effusions,  tumours,  ad- 
hesions, infiltration,  or  stenosis  of  the  air-passages, 
were  unable  to  expand,  would  take  excessive  action  of 
this  kind  on  the  heart  and  large  vessels,  and  influence 
the  pulse  in  the  paradoxical  direction.  But  in  these 
cases  the  heart-sounds  would  be  altered  as  regards  time 
and  strength. 

Implication  of  the  heart  does  not  occur  in  the  special 
form  described   by  Kussmaul.      In  this  variety,  whilst 

*  See  Landois'  Physiology,  translated  by  Stirling,  edition  1885, 
p.  148. 


AND  WHAT  TO  FEEL  IN  IT.  67 

the  pulse  falters,  the  heart  rate  and  strength  of  beat  are 
not  modiJU  d.  It  is  therefore  manifest  that  the  influence 
at  work  is  not  one  having  its  seat  at  the  heart,  but 
beyond  if.  The  first  case  of  pulsus  paradoxus  described 
by  Kussmaul*  occurred  in  a  patient  affected  with  callous 
mediastino-pei'icarditis  (of  Cfriesinger)  and  the  symptoms 
in  this  patient  were  explained  by  the  existence  of  a 
fibrous  constriction  of  the  large  vessels.  The  fibrous 
bands,  becoming  tense  during  inspiration,  occasioned 
increasing  compression  and  temporary  stoppage  of  the 
pulse  with  each  breath.  Intermittent  pressure  on  the 
great  vessels  may  be  set  up  in  a  similar  way  by  a 
variety  of  causes. 

Before  taking  leave  of  this  subject,  it  should  be 
mentioned  that  an  analogous  influence  has  been  traced 
by  Mareyt  in  cases  of  intra-thoracic  aneurysm,  the 
blood-pressure  falling  during  each  inspiratory  phase. 


III. 

The  Incompressible  Pulse — so-called. 

Very  rarely  indeed  can  a  pulse  be  correctly  termed 
incompressible.  In  dealing  with  this  question  we  must 
regard  any  unusual  resistance  offered  by  the  pulse  as 
due  to  the  condition  of  the  artery  itself,  considered  as 
a  tube,  or  to  the  pressure  of  its  contents. 

(1)  As  regards  blood-pressure.  Much  force  may  have 
to  be  opposed  by  the  finger  to  the  vis  a  tergo  propagated 
from  the  ventricle,  and  to  the  resulting  distension  of  the 
artery  between  the  beats,  before  the  resistance  is  over- 


*  Berl.  Klin.  Wochenschr.,  1873,  No.  37-39. 
f  "Circulation  du  Sang,"  1887,  p.  643. 


68  HOW  TO  FEEL  THE  PULSE 

come.  But  in  the  grasp  of  a  healthy  man  there  is 
much  more  power  than  is  necessary  for  this  end. 
Therefore  blood-pressure,  however  high,  is  never  in  itself 
sufficient  to  render  a  pulse  incompressible. 

(2)  As  regards  the  arterial  wall,  it  must  be  borne  in 
mind  that  thin  tubes,  such  as  an  india-rubber  tube, 
originally  soft,  may  through  age  become  so  stiffened 
and  hardened  as  to  break  rather  than  bend  under 
pressure ;  any  tube  of  this  kind  would,  in  a  sense,  be 
incompressible.  Again,  tubes  made  of  a  very  dense 
material,  such  as  glass,  clay,  or  metal,  will,  in  spite  of 
their  thinness,  defy  the  strongest  pressure  that  the 
finger  can  put  upon  them  ;  these  tubes  likewise  are 
incompressible. 

Arterial  Sclerosis. 

Now,  arteries  in  general  are  liable  to  changes  tending 
to  make  them  resemble  either  one  or  the  other  of  the 
above-mentioned  varieties  of  incompressible  tubing,  or 
even  both  varieties  at  once.  Thus,  they  may  become 
sclerosed,  in  other  words,  thickened  and  stiffened  ;  but 
owing  to  their  perpetual  exercise  by  the  heart's  recurring 
systole,  they  never  become  set.  They  may  feel  firm, 
thick,  and  leathery ;  and  may  in  a  measure  resist 
compression ;  but  they  are  never  from  this  cause  alone 
incompressible. 

Calcification  of  the  Arterial  Wall. 

In  addition,  arteries  may  become  partly  solidified 
owing  to  the  deposition  of  calcareous  particles,  in  which 
case,  the  deposition  being  progressive,  absolute  rigidity 
is  a  conceivable  result.  It  is  unusual,  however,  for 
the  calcification  to  proceed  evenly  along  any  consider- 
able length  of  the  vessel ;   and  between  the  calcareous 


AND  WHAT  TO  FEE  J,  IN  IT.  69 

islands  the  artery  preserves  some  of  its  original 
pliability.  The  conversion  of  a  radial  artery  into 
anything  comparable  to  the  stem  of  a  clay  pipe  is 
therefore  very  rare  ;  and  its  absolute  incompressibility 
should  be  classed  among  the  most  unlikely  contingencies. 
But  the  rings  or  patches  of  calcification  may  be  so  ex- 
tensive and  so  close  set  as  to  render  the  artery  relatively 
incompressible,  the  amount  of  force  by  which  its  rigidity 
might  be  overcome  being  undesirable  or  even  dangerous 
to  apply. 

In  conclusion,  a  high  degree  of  calcification  is  the 
only  cause  which  would  render  incompressible  an  artery 
whose  channel  was  still  pervious  and  large  ;  and,  the 
range  of  operation  of  this  cause  being  limited  to  those 
advanced  in  years,  incompressibility,  truly  so  called,  is  of 
rare  occurrence. 

Must  pulses  alleged  to  he  incompressible  ewe  not  so  in 
reality.  The  cause  of  the  erroneous  impression  we 
shall  now  proceed  to  explain,  in  connection  with 
recurrent  pulsation. 


IV. 

The  Recurrent  Pulse. 

Circulation  by  Anastomosis. 

In  peripheral  districts  of  the  circulation,  whenever 
the  channel  of  an  artery  is  accidentally  blocked  by  a 
locally  developed  (thrombotic)  or  by  an  imported 
(embolic)  clot,  or  by  a  surgical  ligature,  the  blood, 
checked  in  its  direct  passage,  finds  a  circuitous  way,  by 
anastomosis,  into  the  distal  segment.  If  the  channel 
of    communication    be    through    fairly   large    arteries, 


•jo 


HOW  TO  FEEL  THE  PULSE 


pulsation  will  appear,  after  a  short  interval  or 
immediately,  in  the  distal  segment;  and  in  this  the 
pulse-wave  will  travel  backwards,  towards  the  heart* 
This  is  the  usual  sequence  after  ligature  for  aneurysm. 

Refluent  Radial  Pulse. 

Precisely  the  same  events  may  occur  when  the 
radial  artery  is  compressed  in  feeling  the  pulse.  If 
digital  pressure  were  kept  up  for  a  sufficient  time, 
recurrent  pulsation  would  ultimately  be  developed  in 
all  subjects  tried  as  to  this  peculiar  phenomenon,  but 
probably  after  varying  delays. 


Fig.  9. 


A  jji 


Illustrating  recurrent  pulsation  at  b',  after  complete  obliteration 
of  the  pulse  at  A.  (Reproduced  with  Dr.  Douglas  Powell's  kind 
permission.) 


In  somr  persons  no  delay  occurs.  No  sooner  is  the 
finger  firmly  pressed  down  on  the  artery  so  as  to  stop 
the  pulse-wave,  than  another  wave  rushes  up  under  the 
testing  finger  placed  a  little  further  down  on  the  course 
of  the  artery.  These  facts  are  excellently  illustrated 
in  the  accompanying  diagrams,  reproduced  from  Dr. 
Douglas  Powell's  paper  on  "Angina  Pectoris,  its  Nature 
and  Treatment"  (in  the  Medical  Society's  Transactions, 


AND  WHAT  TO  FEEL  IN'  IT 


7i 


vol.    xiv.),   with    the    author's    kind    permission.        In 
cases  of  this  kind,  try  what  we  will,  pulsation  persists 

u tauten  tuque  recurrit." 

In  a  word,  the  pulse  is  unswpp 

Nevertheless,  proof  may  be  obtained  that  the  artery 
has  been  effectually  comp  vnd  obliterated  by  finger 

a  ;  and  that  the  pulsation  detected  by  finger  \\ 
reaches  it  from  the  periphery.  This  is  best  done  by 
the  method  suggested  by  Dr.  Douglas  Powell,  and 
illustrated  in  his  second  diagram  (see  Fig.  10).      If  a 

Fig.  10. 


Illustrating  the  mode  in  which  the  pulse  may  be  tested  as  to  its 
complete  obliteration  by  pressure.  (Reproduced  with  Dr.  Douglas 
Powell's  kind  permission.) 

third  finger  (c)  be  placed  between  the  other  two,  whilst 
powerful  pressure  is  made  on  the  artery  by  both  of 
these  alike,  no  pulsation  will  be  felt  by  the  finger  C. 
A  glance  at  Fig.  1.  p.  11,  will  remind  the  reader  of  the 
collateral  channel  through  which  the  recurrent  pulse- 
wave  takes  its  course. 


CHAPTER  V. 

THE  SIX  CHIEF  MORBID  PULSE  TYPES. 
HOW  TO  TEST  THE  PULSE  AS  TO  TENSION. 


The  chief  morbid  varieties  of  pulse  usually  require 
no  sphygmograph  for  their  diagnosis.  The  student 
should  not  rest  till  he  has  been  given  an  opportunity 
of  feeling  each  of  the  following  typical  pulses  of 
disease  : — 

(1)  The  pulse  of  abnormally  high  arterial  tension, 

(2)  The  pulse  of  abnormally  low  arterial  tension, 

(3)  Thi  pulse  of  mitral  regurgitation^ 
(-1)  The  pulse  of  mitral  obstruction^ 

(5)  The  pulse  of  aortic  regurgitation, 

(6)  The  pulse  of  aortic  obstruction. 

To  these  might  have  been  added  the  pulse  of  hyp  r- 
trophy  and  the  pulse  of  dilatation.  These,  however, 
unless  unusually  pronounced,  are  not,  on  the  one 
hand,  sharply  marked  off  from  some  of  the  extreme 
variations  of  the  pulse  in  health ;  neither  do  they 
greatly  differ,  on  the  other  hand,  from  some  of  the 
other  morbid  pulses. 

Preliminary  Description  of  the  Methods  for  Gauging 
Arterial  Tension  with  the  Finger. 

Whenever  it  is  necessary  to  determine  with  precision 

the  strength  of  the  pulse-wave   and  the  tension  of  the 


HOW  TO  FEEL  THE  PULSE.  73 

radial  artery,  recourse  must  be  had  to  the  sphygmo- 
graph,  a  description  of  which  we  have  not  attempted 
in  these  elementary  pages.  With  the  help  of  that 
instrument  both  the  strength  and  the  tension  can  be 
made  out  in  a  satisfactory  manner.  In  medical  prac- 
tice, however,  information  as  to  the  tension  of  pulse  in 
cases  of  illness  is  a  need  of  every  hour,  although  more 
than  a  minute  is  seldom  available  for  its  attainment. 
80  short  a  time  allows  merely  a  rough  estimate  to  be 
formed  with  the  help  of  the  finger. 

It  is  of  great  importance  to  the  practitioner  that 
this  estimate  should  be  in  every  case  as  rapid  and  as 
accurate  as  possible ;  and  it  behoves  the  student  to 
acquire  experience  in  this  matter  at  an  early  period  of 
his  clinical  training. 

The  practical  method  usually  recommended  has  three 
stages : 

(1)  The  obliteration  of  the  artery  by  pressure  ; 

(2)  The  proof  that  this  result  has  been  attained; 

(3)  The  estimation  of  the  pressure  employed. 

(1)  The  Obliterating  Pressure. 

This  stage  of  the  method  needs  but  slight  description. 
The  hand  of  the  observer  occupies  nearly  the  same 
attitude  as  in  feeling  the  pulse.  But  in  view  of  the 
considerable  force  which  may  be  required,  the  distal 
phalanges  do  not  rest  with  the  flat  of  their  pulp  on 
the  artery,  but  the  whole  finger  is  arched.  If  the 
reader  will  refer  to  Fig.  2,  p.  21,  he  will  obtain  an 
idea  of  the  position  of  hand  and  fingers  best  adapted 
to  this  special  purpose.  It  is  there  roughly  shown 
how  the  middle  and  annular  fingers  should  transmit 
tlu.lr  pressure  vertically  to  the   artery.      One,  two,  or 


74  HOW  TO  FEEL  THE  PULSE 

even  three  fingers  may  be  employed  in  this  manner, 
but  it  is  well  to  reserve  the  index  in  every  case  as  the 
exploring  or  t<  sting  fingt  r. 

Fig.  11,  which  is  taken  from  Dr.  Douglas  Powell's 
diagram,  shows  the  effect  of  the  obliterating  pressure 
on  the  artery. 


Showing  complete  stoppage  of  the  pulse  by  the  pressure  of  the 

finger. 

(2)  The  Test  for  Successful  Obliteration. 

Whenever  no  pulse  can  be  felt  by  the  index  beyond 
the  fingers  compressing  the  artery,  we  are  satisfied  that 
the  pressure  has  told.  But,  supposing  that  a  beat  is 
still  perceived,  we  must  not  too  readily  conclude  that 
obliteration  has  not  taken  place.  On  page  71  will  be 
found  a  statement  of  the  reasons  which  suspend  our 
judgment  in  this  matter. 

The  distal  pulse  which  is  felt  may  be  direct  or  it 
may  be  refluent ;  it  may  strike  the  testing  ringer  on 
its  inner  side  or  on  its  outer  side.  With  the  arrange- 
ment depicted  in  Fig.  2,  p.  21,  it  might  be  supposed 
that  the  index  finger,  which  lightly  rests  on  the  artery 
beyond  the  seat  of  pressure,  would  readily  perceive  the 
difference.  In  practice,  however,  tactile  discrimination 
is   exceedingly    difficult ;     and   this    method   is   suited 


AND  WHAT  TO  FEEL  IN  IT.  75 

only  for  experienced  observers.  We  must,  therefore, 
urge  the  beginner  to  practise  at  first  the  following 
plan  : 

The  Elementary  or  "  Bimanual "  Method  of  Testing 
the  Nature  of  the  Distal  Pulse.* 

Remembering  that  some  habitually  try  the  pulse 
with  only  one  finger,  we  might  assume  that  a  single 
hand  would  give  a  supply  of  fingers  sufficient  for  any 
examination.  Yet  the  present  method  consists  in 
using  both  hands  to  the  same  pulse*  The  object  of  this 
lavish  manipulation  ia  first  to  ensure  that  by  keeping 
them  separate,  the  beginner  will  thoroughly  perform  the 
two  functions  of  applying  pressure  and  of  testing  the 
result ;  and  secondly  to  enable  him  more  readily  to 
make  out  whether  the  wave  arises  from  above  or  from 
below,  in  the  manner  described  on  page  71.  No 
difficulty  in  determining  this  point  can  possibly  exist 
when  four,  or  even  when  three  fingers  are  engaged 
in  testing.  Every  student  should  therefore  master 
this  easy  method  before  attempting  any  other. 

The  "  One  Hand  "  Method. 

This  is  the  proceeding  commonly  in  use.  It  has 
the  advantage  of  greater  simplicity  and  elegance,  and 
leaves  one  of  the  hands  disengaged.  The  position  of 
the  hand  and  of  the  fingers  is  shown  in  Fig.  2,  p.  21. 
Pressure  is  exerted  by  the  middle  and  annular  fingers, 
which  are  so  bent  as  to  bear  vertically  on  the 
artery :     they  are  in   mutual  contact.       The  index    is 


*  The  author  has  pleasure  in  acknowledging  his  indebtedness  to 
his  senior  colleague,  Dr.  Dickinson,  for  the  suggestion  of  this 
method. 


76  HOW  TO  FEEL  THE  PULSE 

placed  at  a  slight  distance  from  them,  and  is  scarcely 
bent.  This  finger  lies  over  the  artery  with  the  flat 
of  the  pulp,  not  with  its  tip.  The  difficult  part  of 
this  method  is  how  to  combine  very  light  pressure  of 
the  index  with  powerful  pressure  of  the  other  two 
fingers.  Nevertheless,  continued  practice  will  enable 
the  observer  to  perceive  even  the  smallest  waves  of  the 
pulse. 

{3)  The  Estimation  of  the  Pressure  needed  for 
Complete  Obliteration  of  the  Pulse. 

Having  ascertained  that  the  pulse  has  been  obli- 
terated, we  proceed  with  our  main  object  which  is  to 
gauge  the  resisting  power  of  the  artery  to  pressure.  In 
the  bv-manual  metlwd  both  hands  are  used  with  great 
attention ;  and  whilst  the  testing  hand  watches  for  the 
disappearance  of  pulse  sensations,  the  other  hand 
gradually  increases  its  pressure,  which  had  been  relaxed 
for  a  moment.  Meanwhile  the  amount  of  energ-v 
expended  must  be  estimated  by  consciousness — in 
physiological  language,  by  muscular  sense.  The  mental 
estimate  thus  formed  is  our  measure  for  the  tension  of 
the  pulse. 


I. 

The  Pulse  of  High  Arterial  Tension. 

High  blood  pressure^  whether  occurring  in  a  dilated 
and  inelastic,  or  in  a  contracted  and  supple  artery, 
invariably  implies  increased  cardiac  effort.  The  greater 
the  resistance  in  proportion  to  the  heart's  strength, 
so  much  the  longer  will  be  the  systoles,  and  the 
intervals  between  them.      Therefore  not  only  will  the 


AND  AVI  [AT  TO  FEEL  IN    IT.  77 

pulse-rate  be  slow,  but  the  pulse-wave  will  be  less 
rapid,  or  of  greater  length  (pulsus  tardus).  The  size 
of  tlie  pulse  is  iii  itself  no  indication  of  the  tension.  A 
pulse  may  be  small  and  tense.  If  it  be  permanently 
large  and  tense  hypertrophy  certainly  exists. 

Tlie  test  for  high,  tension  is  the  long  duration  of  tlie 
wave  under  tlie  finger,  and  the  resistance  which  it  offers 
h>  compression. 


II. 
The  Pulse  of  Low  Arterial  Tension. 

(A)  Abnormally  low  tension  means  on  the  one  hand 
little  vascular  resistance  ;  and  this  may  be  due  to — 

1.  The  arteries  being  relatively  capacious; 

2.  The   quantity  of  blood   within   them   relatively 

small ; 
o.  The  vessels  unduly  yielding. 

(B)  On  the  other  hand  it  means  a  relatively  feeble 
fn  r<l lac  systole. 

In  Corrigan's  pulse  (see  p.  79)  we  have  an  instance 
of  a  very  low  tension,  due  to  the  operation  of  causes 
1.  2.  and  3.  in  spite  of  a  very  powerful  cardiac  systole. 
Ineardiac  dilatation  on.  the  contrary,  causes  1.  2.  and  3. 
are  usually  not  present,  but  the  cardiac  systole  is  un- 
equal to  the  task  of  keeping  up  the  necessary  tension. 
Just  as  in  high  tension  the  tendency  is  towards  a  slow 
pulse-rate  and  a  lingering  pulse-wave,  in  low  tension  due 
to  cardiac  dilatationrapidityofrate  and  shortness  of  wave 
are  the  usual  condition.  If  hypertrophy  should  co-exist, 
or  should  there  be  any  tonic  influence,  medicinal  or 
otherwise,  the  pulse-wave  and  also  the  pulse-rate  may 
improve.      But  so  long  as  the  heart  remains  greatly 


78  HOW  TO  FEEL  THE  PULSE 

dilated,  the  occasional  occurrence  of  rather  strong  beats 
only  serves  to  accentuate  the  smallness  of  others. 

III. 

The  Pulse  in  Mitral  Regurgitation  (not 
Complicated  with  Cardiac  Failure). 

The  features  are  mainly  negative,  but  so  constant  in 
their  occurrence  as  to  be  diagnostic. 
The  regurgitant  mitral  pulse — 

is  not  regular 

is  not  even 

is   not  large 

is  not  strung 

is  not  tense. 
Often  in  the  absence  of  any   marked   failure   of  the 
heart,  but  invariably  when  compensation  has  broken 
down,  the  pulse  becomes 

e  /•//  irregular 

vi  ry  um  ecu 

m  ry  small 

eery  weak 

wry  frequent. 
Nevertheless  under  the  use  of  heart  tonics,  or  when 
the  general  health  is  at  its  best,  intervals  occur  during 
which  the  pulse-rate  is  moderate,  and   the  pulse  may 
be  of  tolerable  size  and  regularity. 

IV. 

The  Pulse  in  Mitral  Stenosis  (not  Complicated 
with  Heart  Failure). 

The  peculiarities  of  this  pulse  are,  as  might  have 
been  surmised,  exactly  the  reverse  of  those  of  mitral 


AND  WHAT  TO  FEEL  IN   IT.  79 

regurgitation.  In  one  particular,  however,  the  two 
diseases  agree,  viz.,  in  the  small  size  of  the  beats.  But 
in  mitral  stenosis  the  pulse  is 

relatively  infrequent  ; 

regular ; 

even  ; 

tense  ; 

lingering  (jnilsus  tardus). 
Thus  whereas  the  clinical  symptoms  and  the   aspect 
do  not  always  avail  to  decide  the  diagnosis  between 
an  onward  and  a  regurgitant  murmur,  the  pulse  may 
afford  us  a  very  decisive  answer. 


V. 

The  Pulse  of  Aortic  Regurgitation, 
Corrigan's  Pulse — or  Water-hammer  Pulse. 

This  remarkable  pulse  is  commonly  called  Corrigan's 
pulse,  because  it  was  first  described  by  that  celebrated 
physician. 

The  water-hammer^  after  which  it  is  also  named,  is 
an  instrument  in  physics,  which  demonstrates  by 
contrast  the  uses  of  the  cushion  of  air  normally  filling 
spaces  apparently  empty.  A  stout  glass  tube  contain- 
ing a  short  column  of  water  is  sealed  whilst  the  water 
is  boiling,  and  allowed  to  cool.  Whenever  the  tube, 
thus  deprived  of  its  complement  of  air,  is  rapidly 
inverted,  the  column  of  water  strikes  with  a  sharp 
shock,  resembling  the  blow  of  a  hammer,  the  lower 
end  of  the  tube. 

This  experiment  is  very  closely  imitated  by  the 
pulse  in  cases  of  incompetence,  i.e.,  imperfect  closure,  of 
the  aortic  valves.      The  arteries,   it   is   true,  are   not 


8o  HOW  TO  FEEL  THE  PULSE 

rigid  like  glass,  neither  do  they  contain  a  vacuum  such 
as  we  have  described,  for  they  immediately  contract 
whenever  their  contents  diminish.  But  in  both  cases 
the  fluid  is  unopposed  in  its  progress  by  any  consider- 
able resistance,  and  strikes  against  the  finger  with  a 
shock  reminding  one  of  the  stroke  of  a  hammer. 


The  Tactile  Characters  of  Corrigan's  Pulse. 

The  features  of  this  pulse,  easily  recognised  by  the 
finger,  are  therefore  the  following  : 

(a)  collapsed  {partly  emptied)  calibre  during  tin- 
inter  rah  ; 

(b)  Large,  hard  and  jerky  ventricular  wave,  the 
shock  of  which,  like  that  of  the  water-hammer,  is 
surprisingly  sudden  and  great. 

(c)  The  third  feature  is  no  less  striking ;  it  has  no 
simile  elsewhere.  Almost  as  suddenly  as  the  wave 
has  appeared,  it  vanishes  again.  The  pulse  seems  to 
pass  rapidly  from  a  very  large  size  to  almost  nothing. 
This  early  and  sudden  collapse  is  typical ;  and  it  is 
for  this  sign  that  the  pulse  is  tested  whenever  aortic 
regurgitation  is  suspected. 

"Why  the  Patient's  Hand  is  to  be  Elevated  in 
Testing  for  this  Pulse. 

In  order  to  intensify  the  peculiarity  just  mentioned 
the  patient's  arm  way  be  held  up  vertically.  Thereby 
the  ventricular  wave  will  hardly  lose  much  of  its 
strength,  but  the  blood  will  drain  away  with  increased 
rapidity  and  completeness  after  the  beat.  If  any  doubt 
had  been  felt  as  to  the  existence  of  aortic  reflux,  it 
would  be  dispelled  by  this  experiment. 

N.B. — In  this  disease  the  arterial  blood  escapes  in  loth 


AND  WHAT  TO  FEEL  IN  IT.  81 

directions:  onwards  into  the  capacious  capillary  system 
and  backwards  into  the  ventricle.  When  the  hand  is 
maintained  elevated,  the  second  of  these  outflows  would 
be  greatly  favoured.  The  venous  blood  being  also 
drained  away,  the  hand  becomes  exsanguine.  The 
normally  erect  posture  of  the  head  would  presumably 
tend  towards  the  same  mechanical  result.  This  should 
be  borne  in  mind  in  connection  with  any  symptoms 
of  disturbed  cerebral  circulation  arising  in  cases  of 
regurgitant  aortic  disease. 

The  Visible  Characters  of  Corrigan's  Pulse. 

Very  large  and  sudden  wave, — early,  complete  and 
sudden  subsidence,  this  is  precisely  the  combination 
which  would  lead  to  visible  oscillations  in  the  super- 
ficial arteries.  And,  as  a  fact,  a  good  observer  soon 
learns  to  diagnose  the  sufferers  from  aortic  regurgita- 
tion at  first  sight,  and  merely  from  the  character  of 
their  pulsation.  The  carotid  pulse,  normally  visible 
only  in  a  few  subjects,  is  here  painfully  evident.  The 
carotid  being  nearer  the  heart  has  a  larger  share  than 
distant  arteries,  both  of  the  excess  of  impulse  and  of 
the  regurgitation.  It  beats  therefore  with  considerable 
violence.  The  same  features  are  visible  on  a  smaller 
scale  in  the  pulse  at  the  wrist. 

The  Progress  of  the  Wave  (according  to  Theory). 

A  priori,  what  should  we  expect  to  take  place  on 
the  approach  of  a  big  wave  in  a  soft,  elastic  tube  which 
had  almost  been  sucked  empty  ?  Precisely  that  which 
we  observe  under  similar  circumstances  in  a  thin  india- 
rubber  tube  partly  collapsed  by  atmospheric  pressure. 
Far  from  opposing  any  resistance  to  the  penetration 
of  fluid,  the  elastic  walls  fly  asunder  with  as  much 

F 


82  HOW  TO  FEEL  THE  PULSE 

force  as  was  expended  in  causing  their  collapse. 
Whereas  in  health  the  advancing  wave  may  have  to 
contend  not  only  with  the  weight  of  so  much  arterial 
blood  ahead,  but  also  with  some  remaining  tension  or 
stretch  of  the  arterial  wall,  with  aortic  reflux,  presum- 
ably, neither  of  these  obstacles  would  obtain  ;  and  the 
strength  of  the  wave  would  be  propagated  to  the 
periphery  almost  undiminished.  This  result  would 
be  all  the  more  striking  since  the  wave  leaving  the 
heart  is  larger  and  more  abrupt  than  normal. 

The  Artery  between  the  Beats  (as  Observed). 

Although  we  have  freely  dwelt  on  the  collapsing 
character  of  the  pulse  the  student  should  be  warned 
against  interpreting  these  words  in  too  literal  a 
sense.  Let  him  remember  that  our  statements  refer  to 
that  which  is  felt,  not  strictly  to  thai  which  is.  Having 
made  this  reservation  we  may  now  refer  to  another 
name  given  to  the  water-hammer  pulse.  It  has  some- 
times been  termed  the  pulse  of  unfilled  arteries,  inasmuch 
as  except  for  a  moment  the  contents  of  the  arteries  are 
greatly  inferior  to  the  maximum  arterial  capacity.  Tie 
name  is  not  a  good  one;  it  mentions  imperfect  filling 
which  is  common  to  several  other  conditions,  but  does 
not  refer  to  the  peculiarities  which  exclusively  belong 
to  this  form  of  pulse.  Moreover  it  allows  room  for  the 
misconception  pointed  out  above.  Let  us  state  once 
more  that  arteries  are  never  empty,  even  in  aortic  re- 
gurgitation. Indeed  patients  with  this  disease  often 
enough  display  to  the  eye  the  permanently  full  state 
of  some  of  their  arteries.  The  heart,  after  all,  can 
only  accommodate  a  small  quantity  of  the  total  arterial 
contents  during  its  diastole,  and  in  many  cases  the 
gap   in   the   valve   is  too   small    to  allow   much   back 


AND  WHAT  TO  FEEL  IX   IT.  83 

flow.  It  may  be  asserted  that  it  is  owing  to  the  per- 
sistent fulness  of  arteries  even  in  this  affection,  that 
the  change  about  to  be  described  is  capable  of  arising. 

Arterial  Elongation  and  Tortuosity. 
The  Locomotor  Pulse. 

On  close  inspection  the  radial  artery  is  seen  to  under- 
go with  each  beat  a  powerful  and  sudden  distension. 
Not  only  is  its  calibre  visibly  increased,  almost  enabling 
the  eye  to  follow  the  progress  of  the  pulse-wave,  but 
the  artery  also  elongates  in  a  noticeable  manner, 
Owing  however  to  the  fibrous  connections  of  the 
arterial  sheath,  the  elongation  cannot  be  linear,  like 
that  of  a  rigid  tube,  but  sooner  or  later  leads  to  the 
formation  of  I  mad  curves,  or  of  loops.  With  each  re- 
curring systole  these  curves  undergo  visible  displacement. 
Hence  the  name  locomotor  pulse  which  has  been  given 
to  this  condition. 

Tortuosity  of  an  artery,  as  a  permanent  change,  has 
already  been  mentioned  among  the  signs  of  diminished 
elasticity.  Tortuous  pulses  are  almost  always  loco- 
motor, because  under  the  powerful  wave  from  the 
hypertrophied  left  ventricle,  some  of  the  curves  tend 
to  be  straightened  after  the  fashion  of  the  tubular 
spring  of  an  aneroid  barometer,  wrhile  other  curves 
are  rendered  more  convex.  In  both  cases,  immediately 
after  the  passage  of  the  wave,  the  vessel  returns  with 
a  jerk  to  its  previous  position. 

VI. 

The  Pulse  of  Aortic  Valvular  Obstruction. 

The  difference  between  this  pulse  and  that  of  aortic 
regurgitation  is  analogous  to  the  differences   already 


S4  HOW  TO  FEEL  THE  PULSE. 

described  between  the  two  varieties  of  pulse  in  mitral 
disease. 

The  chief  distinguishing  features  are  : 

(1)  Slotvness  of  rate. 

(2)  Laboured  and  lingering  characterof  wave. 
These  are  the  natural  results  of  the  obstacle  to  the 

discharge  of  the  ventricular  contents,  and  of  the  un- 
avoidable  prolongation  of  the  ventricular  systole. 

(3)  A  distinct  smaUness  in  comparison  with  the  water- 
hammer  pulse. 

(4)  Tension  and  strength — because  the  ventricle 
hypertrophies  under  the  stimulus  of  constant  effort. 

(5)  Evenness. 

(6)  Regularity. 

The  remaining  features  of  this  pulse  are  not  readily 
detected  by  the  finger,  but  can  be  demonstrated  with 
the  sphygmograph. 


CHAPTER  VI. 

ASYNCHEONISM  AND  INEQUALITY  OF  THE 
PULSES.  THE  METHODS  OF  TESTING  FOE 
EQUALITY  OF  PULSE-BEATS,  AND  FOE 
IDENTITY  OF  PULSE-TIME  AT  THE  TWO 
WRISTS. 


In  the  absolutely  normal  subject  the  two  radial  pulses 
are  synchronous,  and  of  the  same  size.  Disparity  in 
size  is  of  common  occurrence  and  often  due  to  causes 
not  implying  disease,  but  want  of  synchronism  is  both 
uncommon  and  of  serious  import,  being  usually  the 
result  of  aneurysm, 

I. 

how  to  test  for  equality  of  the  two  radial 

Pulses. 

This  inquiry  may  be  sufficiently  easy  when  the 
pulses  are  very  different ;  but  it  is  apt  to  be  exceed- 
ingly difficult,  if  the  difference  be  slight ;  and  opposite 
opinions  as  to  which  pulse  is  the  larger  one  are  often 
given  by  separate  observers,  of  the  same  patient. 
In  this  connection  it  should  be  mentioned  that  unequal 
pulses  often  differ  in  other  respects  as  well  as  in  size ; 
and  according  as  observers  are  severally  struck  by  one 
or  by  the  other  difference,  so  their  verdicts  may  be 


S6  HOW  TO  FEEL  THE  PULSE 

various.      It  is  enough  however  for  the  beginner  to 
compare  the  two  pulses  as  to  volume  only. 

Delicacy  of  touch  is  a  special  gift  with  some  ;  with 
most  of  us  it  requires  education.  The  other  indispen- 
sable requisite  is  identity  of  the  experimental  conditions. 
The  two  wrists  must  be  in  identically  similar  positions 
whilst  being  felt — and  the  observer  must  handle  the  two 
pulses  in  some  identical  fashion. 

The  two  best  Positions  for  the  Patient's  Hands. 

(1)  The  most  favourable  attitude  is  the  sitting  posture. 
Both  forearms  are  to  rest  with  their  ulnar  border  on  a 
small  table  on  the  other  side  of  which  the  observer 
takes  his  position.  The  wrists  and  fingers  are  gently 
flexed  so  as  to  brins;  the  right  and  the  left  knuckles 
into  contact.  In  this  way  the  two  radial  arteries  are 
arranged  symmetrically  and  form  part  of  the  same 
semicircular  curve.  We  may  term  this  tlie  first 
position. 

(2)  In  tht  second  position  the  patient  is  seated,  as 
before.  His  hands  are  in  front  of  him ;  but,  instead 
of  being  end  to  end,  they  overlap,  one  being  slightly 
in  front  of  the  other,  as  shown  in  Fig.  12.  In  this 
manner  the  two  wrists  are  in  the  middle  line  and 
separated  only  by  the  thickness  of  the  arm. 

The  two  Methods  which  the  Observer  may  adopt. 

In  both  cases  the  observer  is  to  face  the  patient. 
(1)   If  the  bimanual  method  be  used  the  two  pulses 

are  alternately  tested,  the  right  with  the  observer's  left 
hand,  and  the  left  pulse  with  the  right  hand.  The 
obvious  objection  to  this  method  is  that  the  two  hands 
may  not  possess  the  same  delicacy  of  touch.      It  is 


AND  WHAT  TO  FEEL  IX   IT.  87 

necessary  therefore  to  check  the  result  first  obtained, 
by  crossing  the  hands  so  that  the  right  hand  feels  the 
right  pulse  and  the  left  hand  is  subsequently  applied 
to  the  left  pulse.  Should  the  same  difference  be  again 
detected  between  the  pulses,  it  may  be  assumed  to  be 
a  real  one. 

(2)  The  other  method  does  not  entail  the  same  risk 
of  error,  and  is  far 'preferable.  It  consists  in  feeling  both 
pulses  in  succession  with  the  same  hand.  This  maybe 
carried  out  whilst  the  patient  is  in  either  of  the  two 
positions  described  above.  If  however  the  second  of 
these  positions  be  adopted,  the  pulses  will  be  compared 
with  a  minimum  displacement  of  the  observer's  hand. 
In  conclusion  we  may  therefore  recommend  the  one 
hand  method  awl  the  pat  leafs  second  position  as  t?ie  most 
perfect  combination  for  an  accurate  observation. 

II. 

How  to  Test  for  Synchronism  in  the  Two  Pulses. 

Here  again  the  same  two  positions  are  available  for 
the  patient,  and  one  of  two  methods  may  be  chosen  by 
the  observer.  The  pulses  in  this  case  are  to  be  felt 
simultaneously. 

If  the  bimanual  method  he  preferred,  it  will  matter 
little  how  far  apart  the  hands  may  be  kept.  The 
capacity  for  appreciating  minute  differences  in  time 
between  sensations  conveyed  to  the  two  hands  probably 
varies  considerably  in  individuals. 

The  majority  will  probably  find  it  much  easier  to 
detect  asynchronism  with  the  fingers  of  the  same  hand 
than  with  the  two  hands  separately.  We  are  already 
trained  to  this  method  by  the  ordinary  experience  of 
feeling  the  pulse   with  two    or   three  fingers.     They 


HOW  TO  FEEL  THE  PULSE 


correctly  appreciate  the  feeble  interval  of  time  which 
elapses  between  the  moments  when  the  first  finger  and 
the  last  are  struck  by   the  wave.      I  have   therefore 


Fig.  12. 


Easy  mode  of  detecting  delay  in  one  of  the  two  pulses.     The  hands 
are  sketched  as  they  are  seen  by  the  patient* 

been   led  to  adopt   the    method    represented    in    the 
figure. 

The  patient's  hands  are  to  be  placed  in  the  second 
of  the  two  positions  described  above,  his  right  wrist 
being  nearest  to  his  chest,  his  left  wrist  immediately  in 


AND  WHAT  TO  FEEL  IN  IT.  89 

front  of  the  right,  and  therefore  nearest  to  the  observer. 
The  latter  now  grasps  both  wrists  undei  his  right  hand, 

the  left  wrist  fitting  in  between  the  thumb  and  index, 
whilst  the  three  remaining  fingers  reach  over  the  radial 
border  of  the  right  arm.  With  a  little  practice  the 
full-grown  hand  has  no  difficulty  in  spanning  both 
wrists.  It  is  important  however  to  manage  their 
fixation  entirely  by  means  of  the  thumb  and  the 
annular  and  little  finger.  The  special  office  of  the 
index  and  of  the  medius  is  to  find  the  two  pulses, 
and  to  feel  attentively  for  any  difference  in  time,  if 
it  should  exist.  For  the  better  control  of  the  two 
wrists  (the  patient  being  at  first  awkward  and  stiff), 
it  may  be  advisable  to  support  them  and  hold  them 
in  contact  from  below  with  the  left  hand. 

Check  Observations  Essential. 

However  great  the  care  bestowed  upon  the  opera- 
tions described  in  this  chapter,  it  should  be  an  invari- 
able rule  to  compare  one's  own  results  with  those  of 
another  observer ;  and  a  third  opinion,  of  greater 
experience,  may  have  to  be  obtained.  Thereby  addi- 
tional confidence  will  be  gained  by  good  observers, 
whilst  others  will  be  made  conscious  of  a  need  for 
further  practice. 


CHAPTER   VII. 
CAPILLARY    PULSATION. 


Capillary  blood-vessels,  even  when  dilated,  are  not 
singly  visible  to  the  naked  eye.  Yet  we  may  judge 
of  their  size  with  some  accuracy,  thanks  to  their  vast 
numbers,  their  close  order,  and  their  transparency. 
The  blood,  showing  through  their  walls,  gives  rise  to 
varying  effects  of  colour  (i.e.  complexion)  according 
to  its  amount. 

The    larger  blood-vessels,   on  the  contrary,  having 
opaque   walls,   and  lying    at   a  greater  depth,  do  not 
contribute  in  the  same  manner  to  the  colouration  of 
surfaces. 

Elasticity  and  Contractility  of  Capillaries. 

Capillaries  are  in  a  high  degree  dilatable  and  elastic  ; 
holding  much  blood  when  dilated,  they  almost  exclude 
blood  from  their  channel  when  contracted.  The  result 
of  dilatation  is  Mush,  and  the  result  of  contraction  is 
Pallor.  The  flush  or  the  pallor  may  be  passing  or 
lasting ;  if  the  latter,  we  infer  (excluding  of  course 
changes  in  the  quality  and  quantity  of  the  blood  as  a 
whole)  that  the  change  in  calibre  is  rather  a  passive 
than  an  active  one,  and  that  the  capillary  dilatation  or 
contraction  is  in  connection  with  a  local  supply  of  too 
much  or  too  little  blood. 


HOW  TO  FEEL   THE  PULSE,  91 

To  what  extent  true  capillaries  are  capable  of  active 
and  independent  contraction  long  remained  a  vexed 
question,  all  the  more  difficult  to  solve  owing  to  the 
high  degree  in  which  the  same  properties  are  manifested 
by  arterioles.  They  are  now  known  to  possess  a  con- 
tractility of  their  own,  but  it  is  still  admitted  that  the 
arterioles  are  the  most  active,  although  not  the  only, 
regulators  of  the  blood- supply  to  the  capillary  area, 
and  therefore  of  the  calibre  of  capillaries  them- 
selves. 

Capillary  Pulsation  normally  Absent. 

Since  blushing  and  blanching  are  visible,  any 
systolic  and  diastolic  variations  in  the  calibre  of 
capillaries  should  also  be  visible,  especially  if  occurring 
on  a  large  scale.  Xo  change  of  this  kind  is  percep- 
tible in  health.  From  this  we  infer  that  normally 
capillaries  do  not  pulsate  ;  and  that  the  pulse- wave  is 
extinguished  before  it  reaches  them,  by  the  large  fric- 
tional  and  elastic  resistances  of  the  arterioles. 


Pathological  Occurrence  of  Capillary  Pulsation. 

In  some  functional  and  mechanical  defects  of  the 
circulation  this  rule  does  not  apply  and  capillaries  may 
pulsate.  It  is  then  obvious  that  the  peripheral  resist- 
ances must  have  diminished,  or  the  force  of  the  systole 
must  have  increased  beyond  the  normal ;  or  perhaps 
that  both  changes  may  have  occurred  together.  A 
full  discussion  of  this  subject  would  take  us  beyond 
the  elementary  lines  to  which  we  are  bound.  It  will 
suffice  for  the  student  to  remember  that  relaxation  of 
the  arterioles  is  the  main  cause  of  the  transmission  of 
a  pulse- wave  to  the  capillaries,  because  it  increases  the 


92  HOW  TO  FEEL  THE  PULSE 

width  of  the  blood  channels,  and  because  it  removes 
the  buffer-action  which  arterioles  normally  oppose  to 
the  systolic  shock. 

The  Methods  for  Detecting  Catillaky  Pulsation. 

The  conditions  which  render  capillary  pulsation 
perceptible  generally  require  to  be  brought  about ;  they 
seldom  chance  to  be  ready  made.  The  facility  with 
which  it  may  be  detected  varies  much  with  the  natural 
tint  of  the  complexion,  and  with  the  range  of  the 
oscillations  which  occur  in  the  calibre  of  the  capillaries. 
Under  the  most  favourable  circumstances  it  is  not 
easily  seen  at  first  by  the  untrained,  and  requires  to 
be  pointed  out  to  most  beginners.  Although  lying  at 
the  surface,  it  is  not  an  obtrusive  phenomenon,  and 
for  this  reason  its  existence  was  probably  not  even 
suspected  until  Quincke  called  attention  to  it.  An 
important  reason  explaining  the  long  delay  of  this  dis- 
covery is  the  fact  that  those  who  are  the  subjects  of 
capillary  pulsation  are  apt  to  be  pallid  (as  in  chlorosis  and 
aortic  regurgitation),  whilst  an  essential  for  the  detec- 
tion of  this  pulsation  is  the  existence  of  a  capillary  flush 
of  which  the  variations  may  be  watched. 

The  production  and  the  observation  of  this  flush  lie 
at  the  root  of  the  three  methods  which  have  been 
devised  for  the  clinical  demonstration  of  capillary  pul- 
sation. We  may  conveniently  refer  to  them  under  the 
following  names, 

I.   The  "tache"  method. 
II.   The  "lip"  method. 
III.    The  "nail"  method. 

All  three  should  be  tried  first  in  the  healthy  subject^  in 
order  to  demonstrate  the  normal  absence  of  this  sign  ; 


AND  WHAT  TO  FEEL  IN  IT.  93 

and  next  in  cases  of  extensive  aortic  regurgitation,  where 

they  will  never  fail.      For  the  diagnosis  of  this  disease 
they  possess  much  value. 

I.  The  "Tache"  Method. 

Leaving  aside  theoretical  questions  as  to  the 
mechanism  of  production  of  the  tache  ciribrale  of 
Trousseau  (which  he  believed  to  be  diagnostic  of 
tubercular  meningitis),  we  will  simply  deal  with  the 
transitory  cutaneous  blush  obtainable  in  all  persons  after 
a  sharp  and  short  local  stimulation.  For  our  present 
purpose  the  abdomen  is  not  the  part  best  suited.  We 
would  rather  select  a  situation  such  as  the  forehead, 
where  the  cutaneous  capillaries  are,  under  normal  cir- 
cumstances, very  active,  where  the  skin  is  somewhat 
thin  and  slightly  on  the  stretch,  and  especially  where 
it  immediately  overlies  a  bony  surface. 

The  tache  originally  observed  by  Quincke  was 
brought  out  by  the  pressure  of  a  tightly  fitting  hat. 
This  accidental  experiment  contains  a  useful  sugges- 
tion. Instead  of  the  rough  and  inelegant  proceeding 
of  drawing  a  finger  across  the  forehead,  let  a  band  or 
belt,  or  better  still  a  light  strap,  be  tightened  round  the 
forehead;  a  tacliewill  then  be  produced  secundum  artem, 
and  without  much,  if  any,  discomfort  to  the  patient. 

How  to  Examine  the  Tache  for  Pulsation. 

If  the  patient  be  pale,  any  existing  capillary  pulsa- 
tion may  be  sufficiently  marked  to  reveal  itself  to  the 
first  attentive  look,  the  pink  patch  almost  disappearing 
after  each  pulsation.  More  often  however  the  blush 
is  so  deep  that  the  pulsatile  change  in  colour  is  merely 
a  change  in  the  intensity  of  the  red.      Even  here  how- 


94  HOW  TO  FEEL  THE  PULSE 

ever  more  telling  alternations  of  'pallor  and  of  injection 
will  bt  found  at  tJu  pt  ripTu  ry  of  thi  patch,  over  a  zone  of 
varying  width  :  and  it  is  this  region  that  we  should 
more  especially  scrutinize.  The  ability  to  perceive  the 
capillary  pulse  is  in  great  measure  a  matter  of  visual 
accommodation.  The  focal  distance  for  fine  perception 
of  colour  is  not  the  same  as  that  for  clear  definition  of 
outline  ;  and  therefore  we  should  almost  avoid  looking 
at  the  surface-texture  of  the  skin.  From  thirty  to 
forty  centimetres  is  the  distance  usually  recommended. 
Each  observer  however  must  find  for  himself  the  range 
at  which  the  colour  changes  will  best  strike  the  eye; 
and  for  the  same  reason  he  should  not  neglect  to  move 
the  head  towards  and  away  from  the  patch  under  obser- 
vation, before  finally  concluding  that  pulsation  is  not 
present  in  it. 

II.     The  "  Lip  "  Method. 

Inasmuch  as  the  patch  to  be  watched  is  in  this  case 
a  pale  patch,  this  method  is  the  converse  of  the  preced- 
ing ;  but  since  in  both  cases  an  alternation  of  pale 
and  of  pink  is  the  object  sought  for.  the  results  will  be 
identical.  The  patient's  lower  lip  is  to  be  everted  ; 
and  on  its  mucous  surface  is  applied  with  gentle  pres- 
sure the  flat  surface  of  a  glass  slide.  This  will  produce 
a  central  patch  of  pallor.  We  now  watch  through 
the  glass  the  outer  margin  of  the  pale  patch  ;  and  we 
shall  see  there,  as  we  did  on  the  forehead,  the  alternate 
coming  and  going  of  the  pink  blush. 

There  is  nothing  objectionable  or  painful  in  this 
method,  which  requires  good  light  and  therefore  if 
possible  a  sitting  posture  of  the  patient,  facing  the 
window. 


AND  WHAT  TO  FEEL  IX  IT.  95 

III.     The  "Nail"  Method. 

This  is  in  principle  the  same  as  the  lip  method. 
The  pale  patch  has  its  seat  under  the  nail  instead  of 
under  the  lip.  The  very  gentle  pressure  required  is 
set  up  by  the  tip  of  the  observer  s  nail  applied  over 
the  tip  of  the  patient's  nail  so  as  to  slightly  bend  the 
latter.  The  margin  of  the  blanched  patch  is  to  be 
watched  for  the  pink  pulsation  as  in  the  preceding 
experiment. 

The  "  nail  to  nail n  method  has  this  special  advantage 
that  the  observer  can  watch  simultaneously  his  own, 
presumably  normal,  capillary  blush  as  a  standard  of 
comparison.  Moreover  it  is  possible  to  varv  and  reon- 
late  to  a  nicety  the  pressure  and  therefore  the  depth  of 
the  capillary  injection.  Lastly  the  experiment  can  be 
kept  up  for  any  length  of  time. 

Backward  or  Regurgitant  Capillary  Pulsation. 

A  capillary  pulse  may  be  obtained  in  cases  of  extreme 
tricuspid  valvular  defect.  It  was  first  described  by 
Grocco  in  1885.  It  may  be  observed  under  the  nail 
in  the  same  manner  as  the  direct  eapillarv  pulse. 

Mode  of  Distinguishing  the  Backward  from  the 
Onward  Capillary   Pulsation. 

In  addition  to  the  assistance  derived  from  the  ex- 
istence of  a  venous  pulsation  of  regurgitant  type,  two 
rules  are  given  by  Grocco,  either  of  which  should 
enable  us  to  establish  the  character  of  the  pulsation. 

(1)  The  backward  capillary  pulse  is  not  abolished 
as  would  be  the  case  with  the  onward  pulsation,  by 
compression  of  the  subclavian,  of  the  brachial,  or  of 
the  radial  artery  of  the  same  side  ; 


96  HOW  TO  FEEL  THE  PULSE 

(2)  The  pink  blush  precedes  the  radial  pulse,  instead 
of  following  upon  it,  as  the  onward  capillary  pulsation 
must  do. 

Local  Throbbing. 

Capillary  pulsation,  if  excessive,  may  show  itself  by 
visible  change  in  volume.  The  variation  of  colour 
which  was  described  above  implies  alternating  phases 
of  hyperemia  and  of  pallor ;  but  should  the  amount  of 
blood  stored  in  a  part  be  very  large,  though  pulsation 
may  occur,  pallor  will  not.  Each  systole  will  effect 
further  distension  in  previously  overloaded  vessels ; 
and  the  tissues  themselves  will  be  further  stretched,  in 
short  will  pulsate.  Throbbing  may  be  subjective,  that  is, 
it  may  be  felt  when  it  cannot  be  seen.  Usually  how- 
ever the  feeliug  of  throbbing  corresponds  to  an  active 
visible  throbbing  of  the  part,  and  of  this  it  would  be 
possible  with  suitable  apparatus  to  take  a  tracing. 
The  condition  in  question  may  be  artificially  produced 
by  placing  an  india-rubber  band  round  the  thumb.  It 
is  painfully  obvious  in  abscesses,  and  especially  in  the 
variety  known  as  whitlow. 

Similar  oscillations  of  volume  of  slighter  extent 
are  continually  occurring  in  our  limbs  and  organs  ;  and 
in  some  situations  they  can  be  made  visible  by  the 
plethysmog  raph. 


CHAPTER   VIII 
VENOUS     PULSATION. 


The  subject  of  this  chapter  is  a  large  one,  ill-suited 
for  exhaustive  treatment  in  these  pages.  A  brief 
sketch  however  should  be  of  use  to  the  clinical 
student ;  and  this  will  be  most  conveniently  divided 
into  two  sections, 

I.     Venous  pulsation  in  general,  the  theoretical  part, 
and 

Pulsation  in  particular  veins,  and  especially  in 
the  jugular  veins,  the  practical  and  essentially 
clinical  part  of  the  inquiry. 


II. 


I. 
Venous  Pulsation  in  General. 

Setting  aside  the  rhythmic  venous  pulsations  in  the 
bat's  wing,  originally  described  by  Wharton  Hood,  and 
the  pulsation  of  the  cardiac  extremity  of  the  pulmonary 
veins  in  various  animals  and  in  man,  veins  do  not 
normally  pxdsate.  Nor  is  this  a  matter  for  wonder, 
since  they  are  separated  from  the  cardiac  influence  by 
the  non-pulsatile  capillary  circulation. 

In  disturbed  function,  or  as  the  result  of  disease, 

G 


98  HOW  TO  FEEL  THE  PULSE 

not  only  the  capillaries  (see  p.  91),  but  the  veins  also 
may  present  a  pulsation. 

Venous  Pulsation  a  tergo  ;    Venous  Pulsation 

a  fronte. 

Whereas  capillaries  are  usually  restricted  to  a 
pulsation  a  tergo,  the  pulsation  of  veins  very  com- 
monly arises  a  fronte.  We  recognise  accordingly  two 
varieties,  the  onward  venous  pulse  and  the  backward 
venous  pulse. 

The  onward  pulse  is  derived  from  the  left  ventricle 
and  propagated  through  the  whole  circuit  as  far  as  the 
veins. 

The  backward  pulse  is  due  to  the  systole  of  the  right 
ventricle  and  often  also  of  the  right  auricle. 

Their  respective  Districts. 

Owing  chiefly  to  the  obstacle  opposed  to  a  venous 
reflux  by  the  valves  of  veins,  any  pulsed  ion  in  the  smallt  r 
p>erip)hcral  veins  is  almost  invariably  onward  in  character. 
For  the  same  reason,  and  for  various  others  also, 
the  true  pulsation  of  large,  centrally  placed  veins  is  in- 
variably backwards. 

True  or  Direct,  and  False  or  Communicated 
Venous  Pulsation. 

Before  proceeding  any  farther  the  student  must 
realise  that  since  most  veins  take  their  course  at  no 
great  distance  from  arteries,  arterial  pulsation  may  be 
conveyed  to  them.  It  is  essential  therefore  in  every 
case  to  determine  whether  the  pulsation  is  truly 
venous,  or  only  falsely  so  called. 

In   addition  to    the   common   form   of    transmitted 


AND  WHAT  TO  FEEL  IX  IT.  99 

pulsation,  we  are  enabled,  with  the  ophthalmoscope,  to 
witness  another  variety  of  venous  pulsation  communi- 
cated, from  the  arteries,  it  is  true,  though  not  directly 
(since  no  pulsation  can  be  seen  in  them),  but  through 
the  medium  of  pulsatili  variations  in  the  intra-ocular 
pressm  ■ . 

In  tricuspid  incompetence  the  retinal  veins  not  in- 
frequently pulsate,  as  a  result  of  venous  reflux. 

How  to  Tell  One  from  the  Other. 

This  is  not  always  possible,  but  the  attempt  should 
be  made.  In  aspect  the  transmitted  (arterial^  pulsa- 
tion is  //'"/■'  abrupt  and  shock-Wei  than  the  truly  venous, 
which  may  be  recognised  by  its  soft   undulatory  rm     - 

ment.  In  order  to  show  the  spurious  character  of 
this  pulsation,  endeavour  by  light  pressure  applied  to 
the  artery  to  isolate  it  from  the  vein.  Or  it  may  some- 
times be  possible  to  abolish  the  arterial  pulsation  above 
the  position  of  the  vein  under  observation  and  without 
causing  any  compression  of  the  latter.  Most  commonly 
however  the  slightest  touch,  by  causing  indirect 
pressure  on  the  vein,  interferes  with  the  pulsation. 

The  Onward  Venous  Pulsation  and  its  Cau.-e-. 

True  venous  pulsation,  of  onward  direction,  occurs 
chiefly,  if  not  exclusively,  in  the  peripheral  venules  and 
veins  adjoining  the  capillary  distribution.  Its  occasioning 
cause  is  analogous  to  that  which  leads  to  capillary  pul- 
sation. The  blood  channels  are  so  much  relaxed  as 
to  offer  no  absolute  obstacle  to  the  passage  of  the  pulse- 
wave  ;  and  this  is  continued,  through  the  capillary 
district,  into  the  veins  as  far  as  a  continuous  column  of 
blood,  unbroken  bv  valves,  extends  within  them. 


ioo  HOW  TO  FEEL  THE  PL'LSE 

Complete  relaxation  of  the  arterioles  and  capillaries 
is  often  limited  to  a  special  locality,  as  in  inflammation. 

Veins  under  these  circumstances  may  pulsate  visibly. 
The  same  is  true  of  veins  coming  from  glands  in  active 
secretion.  But  arterio-capillary  relaxation  may  be  a 
general  process,  and  lead  to  peripheral  venous  pulsation 
in  many  situations.  This  may  be  the  result  of  disease, 
or  it  may  occur  as  a  temporary  and  functional  change. 
The  effect  of  a  full  meal,  especially  combined  with 
alcolvblic  stimulation,  will  be  to  quicken  the  heart's 
action  whilst  strengthening  it,  and  at  the  same  time  to 
relax  the  arterioles  (febris  a  prandio). 

Whilst  this  condition  lasts,  it  is  sometimes  possible 
to  detect  pulsation  in  subcutaneous  veins  of  moderate 
size,  especially  at  the  palms,  at  the  soles,  and  over  the 
face,  forehead,  nose,  and  ears  ;  these  being  the  situa- 
tions where,  according  to  Sucquet.*  communication 
normally  takes  place  between  arterioles  and  venules 
only  slightly  superior  in  size  to  capillaries. 

King's  Method  of  Demonstrating  Venous 
Pulsation. 

In  order  the  more  readily  to  observe  and  demon- 
strate the  onward  venous  pulse  King+  used  fine 
threads  of  sealing  wax  placed  across  the  vein  and 
fastened  with  wax  to  the  skin  close  to  it,  so  that  any 
variation  in  the  vein  would  be  indicated  by  the  long 
end  of  the  thread  projecting  beyond  the  vein.  To  this 
arrangement  he  gave  the  name  of  sphygmoscqpe.  This 
was  the  earliest  pattern  of  tic  lever  sphygmograph  which 
is  now  in  > * s>. 


*  See  Ozanarn,  Joe.  cit..  p.  1007. 

f  Guy's  Hosp.  Sep.,  1837,  vol  ii.  p.  107, 


and  what  to  feel  in  it.  101 

The  Backward  or  Regurgitant  Venous  Pulse. 
Its  Causes. 

This  is  the  only  form  of  venous  pulsation  which  the 
student  need  study  at  first.  The  cause  of  backward 
pulsation  is  invariably  dilatation  of  the  right  auricle, 
and  of  the  great  veins  opening  into  it,  by  a  permanent 
overload  of  blood.  The  orifice  of  the  vense  cavse,  closing 
imperfectly,  does  not  then  exclude  the  blood  which  they 
contain  from  the  influence  of  the  right  auricular  systole; 
if  at  the  same  time,  as  is  usually  the  case,  the  tricuspid 
valve  should  be  incompetent,  the  right  ventricular 
systole  also  takes  effect  upon  the  column  of  venous 
blood. 

A  more  detailed  consideration  of  the  backward  venous 
pulse  belongs  to  the  second  section  of  this  chapter. 


II. 

Pulsation  in  Particular  Veins. — Pulsation  in  the 

Jugulars  and  their  Tributaries. 

Its  Limits. 

The  jugulars  are  the  chief  site  for  visible  true  back- 
ward venous  pulse  ;  and  this  is  readily  seen,  though  not 
easily  told,  from  the  transmitted  arterial  pulsation  which 
is  so  commonly  present  in  them.  The  regurgitant 
venous  pulse  commonly  extends  into  the  facial  vein 
and  its  tributaries,  and  sometimes  into  the  brachial. 
The  extension  of  the  pulsation  is  limited  according  to 
the  length  of  the  continuous  column  of  blood  filling  the 
veins  ;  where  this  stops,  there  also  stops  the  pulsa- 
tion.     If  the  vein  be  full  from   end  to  end,  the   pulse 


102  HOW  TO  FEEL  THE  PULSE 

will    not  always    be.    propagated    through    the    whole 
column,  but  may  only  affect  part  of  it. 

Marey  is  stated  to  have  once  observed  reflex  venous 
pulsation  in  varicose  veins  of  the  leg  *  in  a  subject 
affected  with  disease  of  the  right  side  of  the  heart.  It 
is  very  rare,  however,  to  trace  the  reflex  venous  pulse 
through  the  inferior  vena  cava  beyond  the  hepatic 
veins,  or  through  the  superior  vena  cava  beyond  the 
brachial  veins. 

Backward  Jugular  Pulsation  and  Backward 
Jugular  Flow  (or  Regurgitation). 

These  two  conditions  are  often  associated,  but  not  of 
necessity.  It  is  easily  conceivable  and  probably  often 
occurs  that,  without  any  refluxi  venous  pulsation 
should  be  transmitted  through  the  thin  jugular  valves 
stretched  across  an  otherwise  continuous  column  of 
blood  which  has  been  simply  retarded  in  its  onward 
progress  by  an  over  full  condition  of  the  right  side  of 
the  heart.  This  condition  is  quite  different  from  the 
graver  defect  in  which  not  only  a  pulse-wave,  but  a 
flow  of  blood  finds  its  way  into  the  vein.  Regurgita- 
tion of  the  blood  from  the  auricle  into  the  jugulars  may 
be  taken  as  a  proof  that  not  only  the  tricuspid  valve, 
but  also  the  jugular  valve  is  incompetent ;  and,  when- 
ever reflux  takes  place,  jugular  pulsation  is  necessarily 
present  also. 

Methods  for  Ascertaining  the   Presence   of 
Reflux  into  the  Jugular  Vein. 

The  presence  or  the  absence   of  regurgitation  from 
the  heart  may  generally  be  made  clear  with  the  help 

*  Ozauam,  he.  cit.,  p.  1007« 


AND  WHAT  TO  FEEL  IN  IT.  103 

of  a  simple  experiment.  The  contents  of  the  distended 
jugulars  are  pushed  away  by  running  the  finger  in  an 
upward  direction  (doing  the  vessel.  If  the  tricuspid 
valves  be  incompetent  a  fresh  quantity  of  blood  may 
be  sent  into  the  emptied  channel  by  the  next  ventri- 
cular systole.  Should  they  be  competent,  no  reflux 
will  take  place. 

The  Subcostal  Pressure  Method. 

Another  method  is  based  upon  a  mode  of  exploration 
suggested  by  Dr.  Pasteur  "  for  the  purpose  of  esti- 
mating the  condition  of  the  right  side  of  the  heart."* 
"  Under  certain  circumstances,  a  distension  or  over- 
filling of  the  external  jugular  veins,  apparently  from 
below,  with  or  without  pulsation  or  undulation,  takes 
place  when  pressure  is  exerted  in  the  right  hypochon- 
driac or  epigastric  regions  with  the  flat  of  the  hand, 
the  direction  of  pressure  being  backwards  and  upwards." 
As  a  result  of  a  procedure  of  this  kind,  if  the  jugular 
valve  be  incompetent,  a  regurgitation  would  be  occa- 
sioned into  the  jugular  through  the  intermediary  of 
the  inferior  vena  cava,  of  the  right  auricle,  and  of  the 
superior  vena  cava,  all  of  which  are  supposed  to  be 
distended  with  blood.  In  looking  for  this  sign  the 
observer  should  remember  that  he  is  dealing  with  a 
congested  and  extremely  tender  organ. 

The  Presystolic  and  the  Systolic  Jugular 
Pulsations. 

Let  us  now  examine  more  closely  the  backward 
venous  pulsation  noticeable  at  the  root  of  the  neck  in 
cases    of    tricuspid    and    jugular    incompetence.       As 

*  The  Lancet,  May  15,  1886. 


104  HOW  TO  FEEL  THE  PULSE 

regards  time  this   form   of   pulsation  is  always  either 
systolic  or  presystolic  (auricular-systolic). 

A  diastolic  retraction  of  the  jugular  during  each 
cardiac  diastole  has  been  described  among  the  signs  of 
pericardial  adhesions  ;  but  this  diastolic  negative  pulse 
has  nothing  to  do  with  the  valvular  affections  we  are 
now  considering.  Since  neither  the  superior  nor  the 
inferior  vena  cava  possess  any  valves  capable  of  period- 
ically closing  their  cardiac  orifice,  reflux  into  them 
with  each  auricular  systole  might  have  been  regarded 
as  normal  and  unavoidable.  This  is  however  pre- 
vented by  the  fine  adjustment  of  the  auricular  fibres 
surrounding  the  orifices ;  and  by  the  fact  that  the 
blood  is  urged  onward  into  the  ventricle  as  in  ihediree- 
tion  of  least  resistance.  Both  these  arrangements  are 
disturbed  when  the  auricular  wall  is  stretched  by  the 
presence  of  too  largt  a  quantity  of  blood,  and  when  the 
passage  of  blood  into  the  ventricle  becomes  difficult. 
As  we  might  expect,  the  overloaded  auricle  then  sets 
up  a  backward  pulsation  in  the  jugular  at  the  moment 
of  its  own  contraction,  that  is,  immediately  before  the 
ventricular  systole. 

This  auricular  or  presystolic  pulsation  is  known  by 
its  time,  by  its  rapidity  and  short  duration,  and  fre- 
quently also  by  the  double  oscillation  of  which  it  is 
composed. 

Upon  this  usually  follows  the  systolic  or  ventricular 
pulse-wave,  known  by  its  larger  size  and  greater  dura- 
tion.     Very  often  this  wave  alone  is  perceptible. 

Varying  Degree  of  Jugular  Distension  as  Affecting 

the  Pulsation. 

In  addition  to  the  pulsations  just  described,  further 
changes    are    connected    with   the    varying   degree    of 


AND  WHAT  To  FEEL  IN  IT.  105 

distension  of  the  veins,  under  the  influence  of  lessening 
or  increasing  impediments  to  the  circulation.  In  the 
foregoing  description  we  have  imagined  the  jugulars  to 
be  kept  permanently  full.  But  matters  are  often  com- 
plicated by  their  fulness  not  being  constant  but  intermit- 
tent ;  and,  therefore,  the  visible  pulsation  being  also 
intermittent.  It  then  becomes  necessary  to  distinguish 
between  a  true  blood  reflux  and  a  mere  refluent  blood' 

Wa  Pi  . 

Inspection  of  the  Episternal  Notch  and  of  the 
Supra-clavicular  Fossae. 

A  mere  inspection  of  these  regions  affords  valuable 
indications.      The  student  will  note  the  absence — 

( 1 )  Of  ven  0  us  fulness^ 

(2)  Of  transm  itU  d  arterial  pulsation , 

(3)  Of.  t1'1''   '"'  nous  pulsation  : 

or  if  these  be  present  he  will  proceed  to  describe  them. 
In  addition  to  inspection,  palpation  (especially  deep 
palpation)  of  the  episternal  notch  and  of  the  supra-clavi- 
cular fossa:  will  help  us  in  determining  whether  a 
jugular  pulsation  may  be  merely  the  arterial  beat 
communicated  from  the  arch  of  the  aorta  and  from 
the  innominate  (a  frequent  occurrence)  ;  or,  as  in  the 
case  of  the  subclavian  venous  pulsation,  one  propagated 
from  the  subclavian  artery. 

Backward  Pulsation  into  the  Inferior  Vena  Cava. 
HErATic  Pulsation,  Spurious  and  True. 

The  over  full  condition  of  the  right  auricle  must  make 
itself  felt,  not  only  in  the  superior  vena  cava  and  the 
jugulars,  but  also  in  the  inferior  vena  cava.  Into 
this  vein  the  capacious  hepatic  reins  open  just  below  the 


106  HOW  TO  FEEL  THE  PULSE 

diaphragm,  and  they  receive  a  share  of  the  regurgi- 
tated wave. 

Commonly,  however,  the  pulsation  is  limited  to  the 
primary  divisions  of  these  large  veins.  The  liver 
itself,  already  subjected  to  passive  pulsation  by  contact 
with  the  distended  right  heart,  receives  an  additional 
impulse  from  the  regurgitation  into  the  hepatic  venous 
trunks.  The  resulting  movements  of  the  organ  may 
properly  be  designated  as  transmitted. 

In  a  few  cases  the  intra-hepatic  circulation  is  more 
deeply  influenced,  and  the  regurgitant  pulsation,  ex- 
tending down  the  hepatic  venous  system,  produces  at 
each  systole  a  perceptible  increase  in  the  vclv/nu  of  the 
liver.  If  this  organ,  which,  under  these  circumstances, 
is  always  enlarged,  be  palpated  as  closely  as  possible 
between  the  two  hands,  a  (list ensile  pulse  will  be  per- 
ceived at  each  systole.  This  is  true  pulsation  of  the 
liver,  as  opposed  to  the  transmitted,  spurious,  hepatic 
pulsation,  or  common  diffused  hepatic  impulse,  described 
in  the  preceding  paragraph. 

Arterial  Hepatic  Pulsation. 

It  will  be  noticed  that  the  true  hepatic  pulse  is 
usually  regarded  as  a  venous  and  a  regurgitant  one. 
Since  however  both  the  hepatic  artery  and  the  hepatic 
vein  are  continuous  with  the  portal  capillaries,  pulsation 
might  conceivably  be  propagated  to  the  latter  from  the 
hepatic  artery.  This  would  be  a  direct  or  arterial 
hepatic  pulsation.  Conceivably  also  pulsation  might 
arise  in  one  and  the  same  case  from  both  artery  and 
vein.  As  regards  time,  a  slight  difference  would 
exist  between  the  longer  circuit  of  the  direct  arterial 
pulsation  from  the  left  ventricle,  and  the  shorter  route 
taken  by  the  refluent  pulsation  from  the  right  auricle. 


AND  WHAT  TO  FEEL  IN  IT.  107 

Theoretically  a  single  impulse  would  be  proof  that  the 
hepatic  pulsation  was  entirely  of  one  kind.  But  in 
practice,  since  the  delay  between  the  venous  and  the 
arterial  wave  is  trifling,  it  would  be  exceedingly  diffi- 
cult to  decide,  on  this  ground  alone,  and  in  the 
absence  of  the  usual  signs  of  dilatation  of  the  right 
auricle  and  ventricle,  whether  the  pulsation  was  venous 
or  arterial. 


GLOSSARY   OF  TERMS 

IN   USE  AT  THE  PRESENT  TIME   OR  IX  THE   PAST, 
IN'  CONNECTION  WITH  THE   PULSE.* 


Abdominal  pulsation 

Abortive  beats 

Accessory  beats 

ABorhytkymia  (see  p.  63) 

Anacrotic  pulse 

Anacrotism      (secondary     wave 

during  the  ascent) 
Anastomosis 

Ant-like  pulse  (faintest  pulsation) 
Aortic  pulse 
Arhythrma    or    Arrhythmia  (see 

p.  64 
Asynchronism 
Auricular  pulsation 

Bigeminal  pulse 
Bounding  pulse 

Capillary  pulsation 
Cerebral  pulsation 
Collapsing  pulse 
Compressible  pulse 
Corrigan's  pulse 

Dicrotic  or  dicrotous  pulse 
Dicrotism    (secondary    beat    or 
wave  in  the  pulse) 


Diffluent  pulse 
Direct  pulse 
Distal  pulse 

Epigastric  pulsation 

Equal  pulse 

Even  pulse 

Eurhijthmla  (normal  rhythm) 

Faint  pulse 
Faltering  pulse 
Flabby  pulse 
Flagging  pulse 
Foetal  pulse 
Frail  pulse 
Frequent  pulse 
Full  pulse 

Hard  pulse 
Hectic  pulse 
Hepatic  pulsation 
Heterochronism 
Heteromorphism 
High  tension  of  pulse 
Hurried  pulse 

Hyperclicrotism  (excessive  di- 
crotism) 


*  For  an  explanation  of  the  few  English  words  of  which  the 
meaning  is  not  obvious,  the  reader  is  referred  to  the  corresponding 
page. 

Many  obsolete  expressions  have  been  left  out  which  would  not 
be  understood  without  an  account  of  the  erroneous  pulse-theories 
upon  which  they  were  based. 


no 


GLOSSARY  OF  TERMS. 


Ictus  (the  actual  beat) 
Incompressible  pulse  (see  p.  07) 
Inequality 
Infrequent  pulse 
Intermittent  pulse 
Irregular  pulse 

Jerky  pulse 
Jugular  pulse 

Katacrotism     (secondary    wave 
during  the  descent) 

Laboured  pulse 

Lean  pulse 

Linked  beats  (see  p.  6) 

Locomotor  pulse  (see  p.  83) 

Low  tension  of  pulse  (see  p.  77) 

Meagre  pulse 
Moderate  pulse 

Paradoxical  pulse  (see  p.  66) 
Pararhythmia   (abnormal 

rhythm) 
Peripheral  pulse 
Poor  pulse 

Pulsation  by  anastomosis 
Pulse  of  aneurysm 
Pulse  of  "  unfilled  arteries" 
Pulsus    acceleratus,     &c.       (See 

Latin  list) 

Quick  pulse 

Recurrent  pulse 
Refluent  pulse 
Reflux  pulse 
Regularity  of  pulse 
Regurgitation 
Reptation  of  pulse 
Renal  pulse 
Retardation  of  pulse 
Rhythm 


Running  pulse 

Serpiginous  pulse 
Senile  pulse 
Shabby  pulse 
Shallow  pulse 
Slender  pulse 
Slight  pulse 
Slow  pulse 
Spurious  pulse 
Strong  pulse 
Swift  pulse 
Stumbling  pulse 
Symmetrical  pulses 
Synchronous  pulses 

Tall  pulse 
Tense  pulse 
Thin  pulse 
Thready  pulse 
Thrilling  pulse 
Thumping  pulse 
Tortuous  pulse 
Tremulous  pulse 
Tripping  pulse 
Trigeminal  pulse 
Tumbling  pulse 
Turgid  pulse 

Vehement  pulse 
Venous  pulse 
Ventricular  pulse 
Vermicular  pulse 
Vibratory  pulse 

Uneven  pulse 

Water-hammer  pulse 

Wavy  pulse 

Waxing  and  waning  pulse 

Weak  pulse 

Wiry  pulse 

Worm-like  pulse 


LATIN   LIST. 


Pulsus  acceleratus,  quickened 
acutus,  sharp 
cequalis,  even 
alter  nans  (see  p.  60) 
alius,  deep 
amplus,  wide 
angustus,  narrow 
apertus,  plain  ;  not  latent 
bigeminus  (see  pp.  60-65) 
bix  feriens,  dicrotic 
brevis,  short 

caprizans,  hyperdicrotic 
celer,  swift 
ritatus,  quickened 
concisus,  short  and  defined 
contractus,  small 
creber,  frequent 
debilis,  weak 
deficiens,  failing 
differens,  unlike  its  fellow 
difficilis,  laboured 
durus,  hard 
exilis,  thin 
Jiliformis,  thready 
formicans,  ant-like 
fortis,  strong 
gracilisy  slender 
humilis,  low,  shallow 
impar  citatus,  irregular 
impetuosus,  violent 
inaqualis,  uneven 


Pulsus  incequaliter  incequalis  (see 

p.  60) 
inciduus,  waxing  and  waning 
inordinatus,  irregular 
intermittens,  intermittent 
intermittens  cum  inspiratione 

(see  p.  66) 
i/ttercidens,  interrupted 
intercurrent,  with  accessory 

beats 
languidus,  languid 
latens,  latent 
lotus,  broad 
longus,  long 
magnus,  large 
manifestus,  not  latent 
medius,  middle-sized 
moderatus,  moderate 
mollis,  soft 

myurus,  like  a  rat's  tail 
obscurus,  ill  defined 
obtusus,  thick 
oppresstis,  depressed 
ordinatus,  regular 
oscillans,  oscillating 
paradoxus  (see  p.  66) 
parvus,  small 
plenus,  full 
profundus,  deep 
rarus,  infrequent 
recurrens,  recurrent 


112 


LATIN  LIST. 


Pulsus  reptans,  crawling 
robustus,  strong 
serratus,  saw-like 
spasticus,  jerky 
tardus,  slow 
tensus,  tense 
tremuhis,  tremulous 
trigeminus  (see  pp.  60,  65) 


Pulsus  turgidus,  distended 
vndosus,  wavy 
vacuus,  empty 
raJidus,  strong 
vehemens,  vehement 
relox,  rapid,  swift 
vermictdaris,  worm-like 
ribratu*,  vibratile 


PRINTED  BY  BALLANTYNE,  HANSON  AND  C3. 
LONDON  AND  EDINBURGH 


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The  manaopmpfu  nf  n,d*i~l.  .„~tu 


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